Vendors-What's not to like?

The Easy Button

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In Woody Allen’s movie Bananas, the dictator of the small country San Marcos declares that, “All the children under 16 years old are now 16 years old.” That was easy.

In the movie in my head, “The EHRs of Madison County,” I run customer service for a EHR vendor.  Customers kept calling to complain. I declared, “Tell the all the customers nothing’s wrong with our products.”

That was easy. Does that work for your implementation?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Puppy Training Your Vendor

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Carrie Vaughan, a senior editor of HealthLeaders Magazine published an article in the December 8, 2009 issue titled, “Tips to Build a Successful Vendor-Provider Partnership.”  The link to her article is http://www.healthleadersmedia.com/page-2/MAG-243167/Avoid-the-Vendor-Upsell.

The points about which Carrie wrote are spot on.  I asked Carrie if she would permit me to use those same points as a foundation for this posting, to which she was kind enough to agree.  The four points come from her article.  I encourage you to read her piece, as any points with which you may take umbrage are mine, not hers.

To ensure we take an accurate look at the provider-vendor relationship, we must be willing to acknowledge that healthcare providers are from Mercury and the EHR vendors are from Pluto.  They exist in different orbits, and their business models are very far apart—they never intersect; not in space, and not on your project.

1. Have your own inside expert. Don’t rely on the vendor to tell you what you should be doing.  Never.  Ever.  Unless of course you think the vendor knows more about how you want to run your hospital than you do.  Remember, you select them—not the other way around.

Bringing a vendor into your hospital is a lot like bringing home a new puppy. Both need to know who runs the show. Don’t roll over.  They may not be looking to be led, but if you don’t lead them they will lead you.

You should have the expert on board at the outset, before you select the EHR vendor.  The expert should be your advocate.

2. Establish a specific executive liaison with your vendor.  This is not your new tennis partner.  This should be the person who has the authority to ensure your quantifiable wishes are being met, and whose responsibility it is to deliver the message to his troops, and marshal the resources necessary to get the job done.

3. Specify your contractual objectives. Ensure that the contract is aligned with the clinical and business objectives of the healthcare organization, not the vendor.  Before you can accomplish this, you have a lot of work to do with your team.  You must define your clinical and business objectives.  Often these two groups also have a Mercury and Pluto relationship.  Once you have these, your next task is to deliver these objectives to the vendor and have the vendor tell you in writing what they will meet, what they might meet, and what they can’t meet.  It would be nice to know these before you sign their contract.

4. Involve more people than just the IT staff. Need a rule of thumb, involve as many users as IT people—Mercury and Pluto.  You will need new processes, not just to squeeze an ROI from the EHR, but because many of your old ones have probably been around since the invention Band-Aid.

Each of these recommendations will actually help you and help your vendor be successful.  It will not be an adversarial relationship as long as you manage it.  If you don’t manage the relationship, you won’t have to worry about meeting Meaningful Use—you’ll be too busy selecting a replacement vendor.

One final thought, don’t let the vendor loose unsupervised on the oriental rugs.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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A guest post–An EMR that increases productivity

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The following is a guest blog by James T. Loynes, MD.  During a recent call he told me about an EMR he wrote for his oncology practice.  My initial thought was, “Just what we need, another EMR.”  The more I listened, the more I thought he had something different, something that actually was built towards an eye for best practices.  I asked him if he would tell you about it.  The rest of this is his.

The Path to Excellence Is Under Construction

James T. Loynes, MD

No really, I am not crazy.  I just want to do things better.  That’s the reason I built my own EMR.  I worked with an excellent group of programmers to design my Hematology-Oncology EMR piece by piece over a period of three years.   I fixed every design flaw and mistake.  Problem by problem I made it right.

It wasn’t easy and it wasn’t quick.  I examined how I care for patients.  I evaluated how paper and information flowed through my office.  I met with nurses, secretaries and transcriptionists to determine how we could do things better.  I knew that technology could be a powerful tool to improve patient care.

Even as a medical student, I never understood why it was so hard to find patient information.  Charts could be lost or misplaced.  Medication lists were always a moving target.   Why couldn’t we use technology to make things easier and more efficient?  I was annoyed that I had to dictate the exact same information visit after visit.  I was consistently slowed down because I had to find and repeat documentation.

I listened to stories from patients about other physicians who spent entire visits looking at the computer screen because that is what their EMR demanded.  I saw EMR generated notes that had so much information that it was difficult to read.  I made it a point to avoid these pitfalls.

I needed my EMR to make me better, smarter, and faster.   Since there was not an oncology EMR available that filled my needs, I built my own.  I started by designing a web based program that helped me with my chemo orders.  I designed it to fit my (physician) needs.  I wanted to be more efficient.  I wanted to take better care of patients.  I wanted to be able to find information when I need it.

I like paper!  I know this is EMR blasphemy, so don’t tell anyone.  I can write on it, put it in my pocket, or give it to someone.  It is easy to read and anyone can use it!  You know what else I can do with paper?  I can throw it away or recycle it.  While I like paper, I don’t like to file or find it.  As we all know, maintaining a paper chart demands a huge amount of work.  A tremendous amount of time is spent finding, carrying, copying, thinning, and building a paper chart.  I decided that I need paper, but I wanted my EMR to get rid of the paper chart by electronically putting paper where I can find it on demand.

My EMR is web based.  I can access it with any computer that has internet access.  The system can support one physician or fifty. I have hundreds of templates that I can easily edit.  I have order templates, note templates, chemo templates, and nursing templates.  The system automatically fills in designated portions of the physician notes.  The EMR remembers information from previous notes and places in a manner that allows me to dictate new information only.  Dictation time and expenses are dramatically reduced.  Treatment calendars accurately track chemotherapy dates and cycles.  The nurses can write phone notes, enter vitals, and document core nursing measures.  They can perform medication reconciliation and take verbal orders.   I can easily monitor my billing codes and keep track of information needed for the ASCO Quality Oncology Practice Initiative.  I can build treatment plans and treatment summaries.  The system monitors chart access.  Preliminary notes or chemotherapy orders prep the EMR for improved productivity.   Patient lists speed up chart access.  Medications lists and visit summaries can be printed on demand.

This EMR could be easily altered to accommodate different practice specialties.  What would happen if you had 30 physicians in the same community using this web based EMR?  Providers at a small practice have access to the same technology as the largest practice.  Instead of 30 different methods of documentation, each provider could use the same system.  There would be nothing to download and very little equipment would be needed.   Communication would improve exponentially.  The whole community would save on medical costs because there would be less duplication of efforts.  The work of others could be viewed by all.  In the end, everyone benefits, and patients receive better patient care through the use of technology.  Alright, maybe I am a little crazy, but sometimes that’s what it takes.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Published on HealthSystemCIO.com–vendor darts

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Below is the full article I submitted to HealthsystemCIO.com, Anthony Guerra’s outstanding site for healthcare leaders.  As always, I am flattered that he finds my contributions worthwhile.

Is there a best Electronic Health Records system? Perhaps Cerner, EPIC, GE, or McKesson?  For those who have followed my writing, you’re probably thinking my answer is “None of the above.”

I’ll do one better, and I write this with the utmost sincerity—it does not really matter which vendor you select.  As the EHR vendors reading this pull themselves off the floor, permit me to explain why.  Researching the question this is very little information to support the notion that any of the major hospital EHR systems quantitatively stands out from the others.

There are a few sites that offer user assessments across a range of functions, but those have at most three opinions—not enough to consider statically significant.  There are plenty of EHR scorecards and comparison tools, just not many scores.  The vendors’ sites do a poor job of differentiating themselves from their competitors.  Vendors use superlatives and qualifiers in an attempt to differentiate themselves.  When one considers the basic functions that make an EHR an EHR, the top vendors all have them.  No vendor highlights major clinical or business problems that their solution solves that another vendor does not solve.  Instead, they state they do something better, easier, more flexibly—none of which can be measured by prospective clients.

Imagine, if you were an EHR vendor, and you knew that your product did things to benefit a hospital better than the other vendors, wouldn’t you have an independent competitive assessment, some sort of “Consumer Report” chart and evidence to support why you are better?  Of course you would.  You would highlight your superlatives.  I have not seen one that would be very helpful.  The only information I found that might be worth a read comes from Klas Research, http://www.klasresearch.com/.  However, the names of the modules rated are vendor specific, and none of the vendors use the same names.  It will give you a feel for how a small sample rated features within a given vendor, but there is no data to suggest how those ratings compare among vendors.

Even if there was a good comparison, the other thing to learn from this is all the areas that aren’t listed imply that the vendor is either no better or perhaps worse than the competition.  Cream rises to the top—we are left to choose among brands of milk.

One vendor may have a better medical dictionary than another, yet that same vendor will lack rigor in decision support.  No single vendor seems to have their customers doing back flips in their testimonials.  Some score high in their ability to deliver a complete inpatient solution and fail in their ability to integrate with other vendors.  Others hurt themselves during the implementation, user support, response time, and the amount of navigation required to input data.  Some EHR vendors posit their systems as being better at meeting Meaningful Use or passing all of the Certification requirements.  Ask them to name a single installed client for which they have met these.

Why doesn’t matter which vendor a hospital selects?  The reasoning holds not because all hospitals are the same, rather, it holds because were one to perform a very detailed comparison of the leading EHR vendors with a Request for Proposal (RFP), they would prove to be quite similar.  You might find significant separation if you only compared ten functional requirements.  You would expect to find less separation by comparing several hundred, and quite a similarity if you compare a thousand or more requirements.  The more you look, the more they seem the same.

Although the vendors will differ with respect to individual requirements, when evaluated on their entire offering across a broad range of requirements I would expect each to score within one standard deviation of the other.

Reason 2.  It is possible to find hospitals who will give outstanding references for each of the leading vendors.  It is equally possible to find users in hospitals who have implemented one of the “leading” vendors’ systems who will readily tell you that the purchasing the system is the worst business decision they ever seen.  More to the point, every vendor A has probably had at least one of its implementations uprooted and replaced by vendors B, C, or D.  The same can be said for vendors B, C, and D.

If this is a fair assessment, what accounts for the difference?  How can we account for why one hospital loves a given EHR system and another one hates the same system?  Chances are they both needed about the same solution.  Chances are they received about the same solution.

Here’s the difference.  The hospital who thinks they made a good choice:

  • Had a detailed strategy and implementation plan
  • Paid as much or more attention to process alignment, change management, and training as they did to the implementation
  • Managed the vendor instead of being managed by the vendor.

Simply put—the problem is not the EHR system.

One other thought.  “Pay no attention to the man behind the curtain—the Great Oz.”  Do not put your scarce capital into a solution just because it offers or promises either Certification or Meaningful Use.  Yes, there is much discussion about both of these.  The industry stops and holds its collective breath each time a new set of stone tablets are brought forth from the ONC or CMS.  You can meet Meaningful Use with a Certified system and still wind up with a system the users hate and that does not support your business model.

Here is something else I cannot explain.  For those hospitals replacing a one hundred million dollar EHR with another hundred million dollar EHR, why do they think the second system will be any better?  If the systems are not materially different, the only way to get a different result is by changing behavior, not changing systems.  Why make the same mistake twice?  What could be so wrong with the first implementation that an expenditure of far less than another hundred million could not solve?

What is the cost of EHR 2.0 not working?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Parallel universes–replacing one EHR for another

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Some providers are changing their EHR system.  Why?

Why indeed?  What precipitates the need to change?  I bet if you take the top five or seven EHRs, and compare them to a rigorous set of requirements you will find they all score within one standard deviation of the norm.  You won’t hear that from the vendors, but they are the same with regard to the major functionality.

There is no single vendor who scores head over heels above the others.

I bet if you interviewed their customers you will not find a customer which thinks their vendor is the be-all end-all of healthcare.  In fact, you will learn at best most clients will score their satisfaction with their vendor mediocre. Depending on what numbers you read, you will see failure rates in excess of fifty percent.  Failure, by my metric, has more to do with what someone did or did not do to the application than it has to do with the application itself.  This is a “Do these pants make me look fat?” issue.  Guess what, it’s not the pants.

Is there a single vendor who can state that none of their clients has ever replaced them with one of their competitors? That means if you are thinking of replacing EHR A with EHR B, another hospital is thinking of replacing EHR B with EHR A.  Parallel universes, or is it universi?

The grass will not be greener.  Here is what will.  A lot of hospitals operate with what can best be described as anything but best processes–worst processes.  No EHR can handle those.  Before you begin again, evaluate your processes. Weed out the bad ones, do away with the duplicates.

Are you willing to spend another hundred million or two hundred million dollars to get marginally higher satisfaction? Instead, how much would you have to spend to change your processes, implement a change process, retrain your people, and devise a system to bring in your ambulatory doctors?  It would certainly not exceed nine figures.

EHR need not be a do-over.  For those just getting started, do process prior to implementation, not after.

It’s not the pants.

Are you “The Hospital of Perpetual Implementations?”

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“There is no use trying,” said Alice;
“one can’t believe impossible things.”
“I dare say you haven’t had much practice,” said the Queen.
“When I was your age, I always did it for half an hour a day.
Why, sometimes I’ve believed as many as
six impossible things before breakfast.”

There are a number of people who would have you believe impossible things.  I dare say some already have.  Such as?

“My EHR is certifiable.”

“They told me it will pass meaningful use.”

“We’re not responsible for Interoperability; that happens at the Rhio.”

“It doesn’t matter what comes out of the reform effort, this EHR will handle it.”

“We don’t have to worry about our workflow, this system has its own.”

Sometimes it’s best not to follow the crowd—scores of like-thinking individuals following the EHR direction they’ve been given by vendors and Washington.  Why did you select that package—because somebody at The Hospital of Perpetual Implementations did?

There is merit in asking, is your organization guilty of drinking the Kool Aid?  Please don’t mistake my purpose in writing.  There are many benefits available to those who implement an EHR.  My point is is that there will be many more benefits to those who select the right system, to those who know what business problems they expect to address, to those who eliminate redundant business functions, and those who implement proper change management controls.

Your EHR contract–Until death do us part?

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That’s a long time. There are those who suggest that statement sort of takes away any incentive they had to live forever. They wonder why it couldn’t be somewhat less restrictive like, “for the foreseeable future,” or “until one of us gets bored,” or “renewable every four years.”

Till death do you part. Sort of like you either just purchased or are about to share your future with. Once the figures get beyond two commas, you’re pretty much locked in—for better or for worse. It makes no difference if you’ve outgrown it, no longer need it, figure out you never needed it, found something better. Perhaps next time you can suggest more friendly language as you stroll arm in arm down the EHR contract aisle.

First, you must make the other party think that they need you more than you need them.
The best contract is an agreement that is binding on the weaker party—hopefully your EHR vendor. Here’s a little twist for the next contract negotiation with the EHR vendor.

Vendor: Will you manage my EHR with all your heart?

Manage it till death you part?

C-suite: Yes, I’ll manage with all my heart,

From now until death do us part,

And I will manage it when it breaks,

And when my boss over the coals me rakes,

And when it’s fit, and when it’s sick,

(Oh, CAN’T we finish this contract quick?)

And we will own it when it’s bad,

And we will own it when I’m mad,

And I will still own it when it’s broke,

When all our patients want me to choke,

And when if fails Meaningful Use,

And when its failure cooks my goose,

And I will be none the dapper,

As my career goes in the (you fill in the blank),

While searching the bowels for our old charts,

Since productivity has fallen apart,

I will manage it as you like,

As all our doctors go on strike,

And I will eat green eggs and ham, and I will like them Sam I am.

Comparing EHRs–like measuring how wet is water

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The following is a reply I wrote to John’s post at emrandhipaa.com on

EMR Key Differentiators.  http://www.emrandhipaa.com/emr-and-hipaa/2010/03/07/emr-key-differentiators/comment-page-1/#comment-122817

You are spot-on with your comment about the requirement that they be measurable.  Otherwise everyone will be arguing something as nonsensical as how wet is the water.

Even on the second group of differentiators, one can argue that they are too easily qualified.  “Excellence” and “easier” are difficult terms to measure.  Stating that an EHR was designed for a specialty may be of no more value than stating a Yugo was designed for the sports car enthusiast.

I’d look for differentiators along the lines of the following, and then see if they result in business improvements:

  • Our system requires 25 % fewer clicks per process than systems A, B, and C
  • Our system uses 1/3 less screens to enter X than systems A, B, and C
  • Productivity at hospitals H1, H2, and H3, as measured by factors E, F, and G, is up 12%
  • We are able to see an average of 12% more patients since we started using XYZ
  • Rework and errors by our clerical staff is down 8% since we started using XYZ

These differentiators each translate to measurable increased revenues and decreased costs.

But, for how long will this matter?  The business driver towards EHR seems to be to ameliorate today’s problems.  I believe the future of healthcare is not the EHR, HIE & NHIN.  The future of healthcare is post-EHR, electronic medical records will be in a cloud, and will be here before the paint on the NHIN has dried.

AN EHR introspective–my cardiologist and me

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I apologize for the formatting, it got away from me and I could not fix it

The doc did not smile
Nor did I on that day.
So we sat in his office
Wondering each what to say
It was me and my Doctor.
We sat there, we two.
And he said, “How I wish
You had something to do!”

“You drove all this way                                                                                                                                                                                           Your one visit a year.
You sit there like a plant                                                                                                                                                                                            This must seem quite queer.”

So all we could do was to
Sit! Sit! Sit! Sit!
And we did not like it.
Not one little bit.

And then
something went WHIRR!
How that whirr made us stir!

We looked
Then we saw her step in through the door
We looked
And we saw her
And we waited for more
And Nurse said to us,
“Why do you sit there like that?
I know this is clerical
You don’t know how to type.
But they said this would work
That it wasn’t just hype.”

The vendor’s fibs fooled the Nurse,                                                                                                                                                                       The doc patted her head,                                                                                                                                                                                             “It isn’t your fault                                                                                                                                                                                                           We have all been mislead”

“I know some good games we could play,”
Said the Nurse.
“I know some new tricks,”
Said the Nurse as she stewed.
“A lot of good tricks.
I will show them to you.
Your Doctor
Will not mind at all if I do.”

Then Doctor and I
Did not know what to say.
My doctor was out of ideas
For this day.

“Have no fear!” said the Nurse.
“I will not let you fail.
For you see, here’s a pen                                                                                                                                                                                           And over here is some mail

With a pen in my hand!
I can write on this part                                                                                                                                                                                               And before anyone knows it                                                                                                                                                                                     This will look like your chart.

“Look at me!
Look at me now!” said the Nurse.
My doc was still typing                                                                                                                                                                                                     And he uttered a curse,

“We have had this dumb system                                                                                                                                                                                    We have had it three years                                                                                                                                                                                       And I like it less now                                                                                                                                                                                                         It still brings me to tears”

“And look,” said the Nurse!
“Your EKG is taped to the wall!
But that is not all!
Oh, no.
That is not all…”

“Look at me!
Look at me!
Look at me NOW!
Charting is a lost art                                                                                                                                                                                                     And you have to know how.
I can take your B P
The doc will listen to your heart!
And between the two of us                                                                                                                                                                                       We’ll annotate your chart.”

And I sat on the bed.
My shirt askew on the chair                                                                                                                                                                                             I asked, “Do I like this?”
“Oh, like you really care.”
“This is not a good deal,”
Is what I said to my doc.
“I came here to see you                                                                                                                                                                                               Not to stare at the clock.”

“You sit there and type                                                                                                                                                                                                      But you haven’t a clue                                                                                                                                                                                                 This is not the same work                                                                                                                                                                                                As you used to do.”

“There were times when I’d come here                                                                                                                                                                   And you’d take off your hat,                                                                                                                                                                                      Times when I’d come here                                                                                                                                                                                       And we’d sit here and chat”

“We’d talk how I feel                                                                                                                                                                                                         And things that would matter                                                                                                                                                                                    But now your sit there and type                                                                                                                                                                                  And I hear the keys clatter”

“You’d ask of my meds                                                                                                                                                                                               And inquire of my health                                                                                                                                                                                           And now with this system                                                                                                                                                                                             The conversation’s gone stealth.”

“I must use the system.
We’ve paid quite a lot!”
Even though I don’t care                                                                                                                                                                                               It can sit there and rot.”
“It will NOT go away.
I cannot make it work!
Did not ask what I wanted
Makes me look like a jerk.”

And my doc he ran out.
And, then, fast as a fox,
My doc in his Cole Haans
Came back in with a box.

A big EHR box.
And I gave it a look                                                                                                                                                                                                              “Now along with this box,
All we got was this book.”

Then he stood on his desk
And with a tip of his shoe                                                                                                                                                                                               “This time” he said                                                                                                                                                                                                           “I have something to do.”

“My productivity’s down,                                                                                                                                                                                     Thirty percent by my count,                                                                                                                                                                                         And the attributes of this system                                                                                                                                                                         They want me to flount.”

“It’s only good for two things
neither one is for me                                                                                                                                                                                                        It helps payors and auditors                                                                                                                                                                                       So to them it seems free.”

“They can get all our data                                                                                                                                                                                                  And use it to sue                                                                                                                                                                                                                 Yet for me it is useless                                                                                                                                                                                                       I have not a clue.”

“Oh dear!” said the Nurse,                                                                                                                                                                                                 I call this game…Make EHR Fly,
If I kick hard enough,                                                                                                                                                                                                      It will go to the sky.”

“You cannot play that game...
Oh dear.
What a shame!
What a shame!
What a shame!”

Then he shut off the System
Back in the box with the hook.
And the Nurse went away
With a sad kind of look.

“That is good,” said the doc.
“It has gone away. Yes.
But my boss will come in.
He will find this big mess!”
“And this mess is so big
And so deep and so tall,
We cannot clean it up.
There is no way at all!”

The CIO came in
And he said to us two,
“Did you have any fun?
Tell me. What did you do?”

And doctor and I did not know
What to say.
Should we tell him
The things that we did here today?

Should we tell him about it?
Now, what SHOULD we do?
Well…
What would YOU do
If your CIO asked YOU?

Jihad Joe EHR selection

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When competing hypotheses are equal in other respects, the principle recommends selection of the hypothesis that introduces the fewest assumptions and postulates the fewest entities while still sufficiently answering the question. It is in this sense that Occam’s razor is usually understood.  There is no corollary that works with EHR vendors.

What if we look at HIT vendor selection logically?  Have you ever noticed at the grocery store how often you find yourself in the longest checkout line, or when you’re on the highway how often you find yourself in the slowest lane?  Why is that?  Because those are the lines and lanes with the most people, which is why they move the slowest.

If you are asked in which line is Mr. Jones, you would not be able to know for certain, but you would know that the most probable option is the one with the most people in it.  You are not being delusional when you think you are in the slowest lane, you probably are, you and all the people in front of you.  The explanation uses simple logic.  It’s called the anthropic principle– observations of our physical universe must be compatible with the life observed in it.

It can be argued that the business driver which shapes the software selection process of some is the aesthetics of efficiency, a Jihad Joe approach to expediency.  Buy the same system the hospital down the street bought, the one recommended by your golfing buddy, or the one that had the largest booth at the convention.  Or, one can apply the anthropic principle, rely on the reliability of large numbers and simply follow the market leader.

Might work, might not.  My money is on might not.  There’s still plenty of time to do it right.  If that fails, there will always be time to do it wrong later.  Of course, you can always play vendor darts.  If you do, you should sharpen them so they’ll stick better.