Healthcare IT, let’s not lose site of the patient

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It is easy to remove oneself from what is important as we trade metaphorical tomatoes about what is wrong with EHR, what may happen to the healthcare reform, and why the nationwide health information network is DOA.

Debating healthcare IT on the Internet is an esoteric and antiseptic conversation, one with few if any catastrophic implications to anyone other than the person trying to sell a used, $100 million EHR on eBay.

We write about the fact that it is supposed to do something to benefit the patient. Is there a more sterile word than patient? Whether we use patient or patients, we keep it faceless, nameless, and ubiquitous. They do not have to be real for us to accomplish our task; in fact, I think we do our best work as long as we keep them at arm’s length.

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We calculate ROIs for EHR around people who exist to us only by their patient IDs.

What if these hominoid avatars turned out to be real people? What if indeed?

Recently I learned of a real patient; a friend, 37, mother of three. She has had lots of tests. They call it Myelodysplastic Syndromes. MDS sounds more polite. One would think that because it has its own acronym that might imply good news. It does not.

The thing I like best about Google is knowing that if an answer exists, I can find it. I may have to vary the syntax of the query a few times, but sooner or later I will find what I seek. The converse can be quite disquieting, especially if you happen to enter a phrase like, “survival rates for MDS.” After a few tries I realized that the reason I was not getting any hits to my query had nothing to do with poor syntax. It had everything to do with a lack of survivors.

“Last Christmas” is a rather strange title for a blog. In this instance the title has nothing to do with anything religious. It is simply a line in the sand, a statement with a high degree of probability. Unfortunately, “Last Christmas” does not have the same meaning as the phrase, “this past Christmas.”

My friend has had thirty-eight Christmases. Apparently, MDS is able to alter simple mathematical series. If presented with the numerical series 1, 2, 3. . .37, 38, 39, and if we were asked to supply the next number, we would all offer the wrong answer–40. In her case there may be no next number; the series will likely end with 39. That’s MDS math.

Then there are the three children, each one of them in the same grade as my three children. They will be learning a different version of MDS math. All the numerical series in their lives will reset and begin again with the value of one. First Christmas since mom died. First birthday since mom died. Every life event will be dated based on its relationship to an awful life-ending event.

It will be their B.C. and A.D.

EHR probably has very little value when you break it down to the level of an individual patient. Stalin said something like, “one death is a tragedy, and a thousand deaths is a statistic.” While it is unlikely that he was discussing patient outcomes, the import is the same.

Rule One: There are some awful diseases that will kill people.
Rule Two: Doctors are not allowed to change Rule One.

I guess it goes to show us that as we debate things that we view as being crucial components of whatever lies under the catch-all phrase of healthcare, when it comes down to someone you know who probably is not going to get better, some things do not seem very important.

How to recover your lost EHR productivity

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Success and failure are often separated by the slimmest of margins. Sometimes you have to be prepared to think on your feet to out think unfavorable circumstances. Sometimes success hinges on how you present your idea. It is possible to force the circumstances via rapid evolution to pass from problem, to possible solution, to believable, to heroic? I believe so.

Permit me to illustrate with frozen chicken. Several hours before dinner I threw the frozen chicken breasts into the sink, choosing to thaw them with water instead of the microwave. Some twenty minutes later while checking emails I wondered what we were having for dinner. Not to be outdone by own inadequacies, I remembered we were having chicken. I remembered that we were having chicken because I remembered turning on the hot water. The only thing I couldn’t remember was turning off the hot water.

I raced to the kitchen. My memory of having forgotten to turn off the water was correct. Grabbing every towel I could find, I soaked up the puddles from the hardwood flooring, thinking while mopping about how I might answer to my wife if she happened to return to a kitchen that looked like the Land of Lakes. My first reaction, admittedly poor, was to tell her that I thought the countertop wasn’t level and that the only way to know for sure was to see which direction the water ran. Telling her the truth never entered my mind.

Once the major puddles had been removed, I worked on version two of the story, quickly arriving at a version of the truth that seemed more palatable—tell her I decided to wash all the towels. Why not get bonus points instead of getting in trouble? Version three looked even better. Since I was wiping the floor with the towels, instead of telling her I washed the towels, why not double the bonus points? I decided to wash the floor, and wash the towels. Husband of the year can’t be far off.

A few hours have passed. The floor is dry—and clean, the towels are neatly folded and back in the linen closet, and the chicken is on the grill. All the bases covered. A difficult and embarrassing situation turned into a positive by quick thinking.

A few of you have asked, let’s say we buy into what you are saying, how do you propose we turn around the results of our EHR implementation? All kidding aside, it comes down to presentation. Clearly you can’t walk into a room with a bunch of slides showing that your EHR investment was wasted. Additionally you cannot hide the fact that your productivity is dropping faster than Congress’ favorability polling.

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

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

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

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

So, how did my chicken dinner turn out? I was feeling confident that I had sidestepped to worst of it. Overconfident, as it turned out. My son hollered from the basement, “Dad, why is all this water down here?”

 

EHR’s marmalade-and-toast hypothesis

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Les choses son contre nous—things are against us.  EHR is the marmalade-and-toast hypothesis, that the marmalade-side will land on the carpet when the toast falls from the breakfast plate, played out in bits and bytes.  Resistentialism is the belief that inanimate objects have a natural antipathy towards human beings.  If one were to view the marmalade-toast through the glasses of resistentialism one would conclude that the likelihood of the toast laying marmalade-side down increases with the cost of the carpet. So it is with the EHR.  Your expensive EHR is laying marmalade-side down on a very expensive carpet.

EHR has created an air of technostalgia with users yearning for the bygone days when the technology involved a number two pencil and a pad of paper.  Now that you are using your EHR system, do you ever wonder how different the experience of using it would have been if someone had asked for your input about what the EHR should do?  Would merely asking have solved the EHR myopia that was brought about by those who implemented it, implemented it without involving a single systems designer?

That this problem even exists is demonstrated by the fact that to use the EHR required hours of training.  Users sat there like sock puppets listening to the buzzword-bingo put forth by the trainers.  This should have been the clue that none of what they were about to learn was intuitive or self-evident.  The reason they offer EHR training is to explain “This is how you get the system to do what you need it to do,” because without viewing it that way it will not do anything.

The EHR has turned a lot of normally complacent physicians and nurses into stress puppies.  To understand how far amiss the functioning of the EHR is from what the users had hoped it would be all one has to do is observe it being used.  How many doctors and nurses have apologized to a patient during an exam because of something related to the EHR?  “Sorry this is taking so long…If you will just bear with me while I figure out how to do this…When the nurse returns I will get her to show me how to schedule your next appointment.”

If ever there was a time to have employed defensive pessimism, the implementation of EHR was such a time.  Users went into the project skeptimistic, certain it would go badly.  As niche worriers doctors and nurses imagined all the ways that the EHR would under deliver and would make their jobs more difficult, and they watched their stress portfolios rise.  The forgotten task was that nobody mapped out ways to avert the damage.

That this jump-the-shark problem can and should be corrected by something not much larger than a two-pizza team—a team small enough that it can be fed by two pizzas—seems to have escaped the reason of many.

Many are guilty of treating the productivity drop brought on by EHR as a problem with no solution.  If a problem has no solution it is not a problem, it is a fact.  And if it is a fact it is not to be solved, but coped with over time.  There is way too much coping going on.

The EHR productivity drop can be undone.  It will not be undone by redoing the training.  It will be undone by assessing the human factors and user experiences of those using the EHR, by researching how they users want to use it, and by reconfiguring the user interface.

This is not cheap, but it is much less expensive than the cost of loss productivity.

 

A thought for Thanksgiving

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May I take you on a tour of our homes—yours and mine?  Although we’ve never crossed one another’s thresholds, we’ve been there, at least if you live in America. Take the tour with me.  You enter through the front door.  On one side is the living room, on the other sits the dining room.  If you’re left-handed, as am I, the dining room is on the left and the living room is on the right.

The living room looks exactly like it did the day the movers dropped off your furniture.  It might as well be cordoned off with red velvet rope and polished brass stanchions.  It reminds me of taking the tour of Independence Hall, seeing the quill pen right where Mr. Hancock left it.  Nothing has been disturbed.

We don’t use our living room.  We vacuum and dust, just like everyone does.  We didn’t use it when I was young; I’m starting to think it might be a better spot for a hot tub.

Opposite the living room is the dining room.  One or two brass chandeliers, depending on your tastes.  Oriental rug, side board, hutch.  Ask a thief about the rest—bone china, a velvet lined box of silver dinner wear.  Candlesticks.  Hand cut lead crystal.  Linens; tablecloth and napkins.  That sort of covers it.

If your family is at all like mine, when the dining room isn’t being used for folding laundry, building 1,000 piece puzzles, or tax preparation, it is used for high holidays, proms, weddings and funerals.

We have a set of china I bought from England on eBay that is more translucent that Saran wrap.  We’ve probably used it a half dozen times.  It’s for those special occasions—like the passage of the healthcare reform bill.

Eight years ago this Thanksgiving I was sitting on the floor of the dining room, inspecting the dishes and silverware when I came upon an unopened box of off-white tapered candles that was tucked away under the starched Egyptian cotton linens.

It gave me pause.  The receipt was taped to the box—purchased five years ago.  Why?  In case we needed them.  In case there was an occasion so special as to warrant candles, better yet, candles in the dining room, with the china and lead crystal.  (Sounds a little like Colonel Mustard in the dining room with the lead pipe.)

At the rate we were going, the candles and china were so well preserved so as to survive an archeological dig in the year 3,000.  What is the correct candle lighting threshold?  What is yours?

I almost never had the chance to learn mine.  Less than two weeks after that Thanksgiving, while watching an episode of the Sopranos, I had difficulty breathing, a lot of difficulty.  Collapsing to the floor while trying to convince my wife I was fine was enough to get her to call for an ambulance.  I was having a heart attack.

Less we be distracted, these few paragraphs are about the candles, not the heart attack.  These days we burn the candles, stain the linens, and break the crystal and the china.

I used to think, wouldn’t it be neat if, or if I had the chance for a do-over I’d like to be.  How cool would it be to have been Ted Kennedy or Paul Newman?  Celebrity.  Impacting world events.  Able to pay John Edwards money for a haircut.  Why not want that?

One reason.  Each of us has the ability to choose to complain about tomorrow, an ability Messieurs Newman and Kennedy no longer have.  Too hot, too cold, too busy, too bored.  The question is, do we also have the smarts, the God-given wisdom, not to complain but just to be grateful for being.

I also had cancer twenty years ago.  I have vivid memories of wishing I was caught in traffic jam on I-75 in Dallas, yet I’m the same guy who often finds himself a nanosecond away from having a news helicopter filming my traffic road-rage.  My moments of clarity wax and wane as I’m sure do yours.

It’s difficult if not impossible to see your candles as you lie strapped to a gurney in the back of an ambulance.

I’ve been fortunate to have met some really special people on the Internet.  Smart people, generous people, people willing to share ideas diametrically opposed to mine.  People caught up in their lives and the lives of others.  People who in an awkward moment would think it might be great to trade their lot for that of another.  People who’d rather save their candles for a more important occasion.

No occasion will ever be any more important than the occasion of having tomorrow.  Let’s agree to light a lot of candles this year.

Warm regards, Paul

The Real Reason Your EHR Failed, And What To Do About It

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This is the title for my new blog at healthsystemcio.com. I would love to read what you think

http://healthsystemcio.com/2011/11/18/the-real-reason-your-ehr-failed-and-what-to-do-about-it/

EHR: What questions remain unanswered?

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“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?

Controlling the Patient Dialog

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Remember when there were 200 firms in the Fortune 100?

How long ago was that? I think it was around the same time when people still thought you shouldn’t wear white after Labor Day. Time to drop-kick those white pumps to the back of the closet. What made me think of that bit of nonsense was a meeting I had recently with one of the sharpest people I’ve had the pleasure to meet professionally, and a classmate of mine from grad school. She happens to be the founder and president of one of the country’s go-to firms for dealing with business ethics. Having served as a board member for several publicly-traded firms, as well as chairing their audit committees, when the Andersen and Enron scandals hit she went looking for professionals who could help her help her firms. When she couldn’t find the help, she created it.

That conversation got me thinking and made me wonder why there were no longer 200 firms in the Fortune 100. Was it; is it, a matter of business ethics? How often do unethical practices come up when firms interact with their customers? A couple of takeaways from the meeting—for board members to be able to meet their obligation, they ought to do more than reply on the meeting book pulled together by the firm they serve. Simply relying on the book presumes ethical behavior, a presumption not always supported by fact—how much should one believe if the information is being provided by someone who purchased a $900 shower curtain?

What can they do? Due diligence is being reinvented, and the Social Network is leading the charge. One example is to go to Yahoo Chat to see what’s really being said about your organization. Other things I’ve done to obtain facts and opinions, things which particularly gauge how customers and employees feel about the firm include Google Reader, Facebook, Twitter, and YouTube, to name just a few. You don’t need patient focus groups to learn what’s being said, or to learn how good a job your hospital is doing. The patients already have a laser focus. In many instances the group lacking the focus is the healthcare provider.

Firms should focus on maintaining a strong Reputation Bank, one strong enough to be able to handle withdrawals, because you never know when there might be a run on the bank. Might be a good time to look at your own bank deposit slips.  Deposits can be made easily through the social media network.  You can’t stop patients from talking about you but you can shape what they say.

EHR’s Unanswered Questions

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Does anyone remember how many of each type of animal God told Moses to put on the ark? Are you sure? For those who missed it, Noah built the Ark, Charlton Heston built the stone tablets.

One word can make the difference between right and wrong, especially if the question is big enough. Who is asking the questions that are shaping your firm’s EHR strategy? Are they asking the right ones? What are the right questions? If you are the person responsible for the money that will be spent on EHR, all of these deserve an answer;

If the ARRA money went away tomorrow, would we still be doing EHR?
May I see a copy of our EHR plan?
Who vetted the plan?
If Meaningful Use went away, would we still be doing EHR the same way?
Would we still have selected this vendor?
What criteria did we use to select the vendor?
What commitments do we have from the vendor about meaningful use?
What commitments do we have from the vendor if meaningful use changes?

These are very basic questions, but I bet if you ask them of your team, you will not be pleased with several of the answers.

EHR’s Kitchen Table Amateurs (KTAs)

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So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were telling stories about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf. She’d mix the ingredients in a large wooden bowl; 1 pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into a loaf, and place the loaf into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as she had learned from her mother. One day he asked her why she threw away the extra instead of cooking it all. She replied that she was simply following her mother’s recipe.  The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the EHR strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. The end results would be no better than sacrificing three goats and a chicken.

So, think about how to define the problem, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

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.