Graphing EHR’s Functionality

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Credit for the graph goes to Mr. John Grace and the Journal of Irreproducible Results.  As you can imagine, I added the bit about EHR.

What Can Your EHR Do for Me?

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This piece of mine was just published in HCPlive.com.

http://www.hcplive.com/hospital-medicine/articles/what_can_your_ehr_do_for_me

Why bother with an RFP for EHR?

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HIT Strategy; without one, do not take out your checkbook.  Buying what your neighbor bought, and assuming they did their homework, is not a strategy.  Buying something because the sales-rep told you they had an amazing list of client references is not a strategy.  These are shortcuts.  Have you noticed none of the EHR providers were not wearing “I love my EHR” T-shirts at the last HFMA meeting?

My rule of thumb about Google is that if I cannot find something it is because it does not exist.  There are no good EHR RFPs available on Google.  Here are a few thoughts on RFPs in case you want to use one—by the way, a good RFP makes a great addition to a vendor contract as it provides a written audit trail of what they contracted to do.

  1. The RFP should have an exhaustive list of requirements.  It is designed to separate one vendor from another, not make them all appear to be equally capable.
  2. The requirements should be addressed in a way to help a provider know what business capabilities the vendor offers, not to show how pretty their screens are.
  3. The RFP should not mirror your current business.  Your goal is not to simply automate what you do, but to do it better.  That means change.  Without change your EHR will simply be an expensive scanner.
  4. Along that same thinking, I have yet to see an RFP that mentions a single requirement about making the provider’s business more efficient or more effective.  Here’s why.  if each provider tells you their system can perform the same tasks as the other systems, you have not learned anything to cause you to pick one vendor over another.  If they say their system is efficient, make them supply you with details about the number of clicks, screen navigations, and times needed to do the ten tasks you do most often.  If they say they are twice as fast as Vendor A, make them prove it, make them prove it in your office.  Contact vendor A and find out who is telling the truth.  If they each have the same functionality, and one vendor takes half the time to perform a task, that fact should be included in your decision.  How important is 30 seconds?  How many 30-second improvements are there with each patient?  If there are four, and you see 30 patients a day, and your practice has eight doctors, you’ve either just saved a total of eight hours a day to spend more time talking to your patients, or to add patients.
  5. The other important part of the RFP that is often either overlooked or under assessed is the specialization of the EHR.  Warning: A large vendor has probably has at least one implementation covering each specialty; cardiology, orthopedics, urology.  Having one or a few clients in a specialty does not mean their product was designed to serve that market.  It may mean their clients did not do a very good job selecting tem as their vendor.
  6. That brings us to references.  A large vendor may have a thousand or more providers installed.  When you ask to check their references, which ones are they likely to parade in front of you—the ones who like their product.  The other 990 are kept in their lock-box.  Whoever they give you to talk to will be those who they feel are least likely to say something negative.
  7. How should you check references?  Most vendors will give you as a contact either a top administrator or someone in IT.  That will tell you very little.  Once you learn the name of the organization, call them.  “This is doctor so-and-so, and I am calling to speak with one of your physicians.”  Whatever this person tells you will be of much more value than having someone who not use the system tell you how much they like it.

Anyway, those are my thoughts.  There are a range of savings available if you have a good EHR strategy, pick a good system, and implement it correctly.  If you pick the wrong one, you do not need to worry about calculating your ROI—there won’t be one.

Patient Relationship Management (PRM)

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If you watch too much television your brain will fry. Sometimes I feel like mine is in a crepe pan that was left sitting on the stove too long. Two nights ago I’m watching Nova or some comparable show on PBS. The topic of the show was to outline all the events that took place that helped Einstein discover that the energy of an object is equal to its mass times the speed of light squared, better known as E=mc². It was presented to the audience at a level that might best be described as physics for librarians, which was exactly the level at which I needed to hear it. It’s physics at a level that is suitable for conversation at Starbucks or any blog such as this.

So here’s what I think I understood from the show. It tracked the developments of math and physics in 100 years prior to Einstein’s discovery. The dénouement appeared to occur when Einstein and his fiancée were riding in the bow of the small boat. Apparently, he was leaning over the side of the boat and noticed that the waves generated by the front of the boat moved at the same speed as the boat. He then noted that fact only held true for those persons in the boat, who were in fact, traveling at the same rate of speed. However for those persons watching from the shore, that same wave was not only moving slower than the boat it got further behind over time. Some other things occurred, yada, yada, yada, and there you have it. Clearly, the details are in the yada, yadas.

So here’s what happens when you watch too much television. As I’m running this morning somehow my mind takes pieces from that show and staples them together to yield the following. Let’s go back to the equation E=mc². For purposes of this discussion I’ll redefine the variables, so that:
E = the percentage of Patient Complaints/Inquiries.
m = Patient in-bound calls.
c = number of Patients
If this were true–this is an illustration, not an axiom–the percentage of complaints in the call centers of an healthcare provider is equal to the number of in-bound calls times the square of the number of patients. So as the number of calls increases the number of complaints/questions increases and as the number of patients increases the number of complaints increases exponentially. Of course this is made up, but there appears to be a grain of truth to it. As a number of calls increase the percentage of complaints is likely to increase, and as the number of patients increases there will probably be an even greater increase in the percentage of complaints incurred. I think we can agree that a reasonable goal for a healthcare provider is to decrease the percentage of complaints and perhaps to shift a hefty percentage of inquiries to some form of internet self-service vehicle.

I think sometimes the way providers like to assess the issue of Patient Relationship Management  (PRM) is by looking at how much money providers throw at the problem. I think some people think that if one provider has 2 call centers, and another provider has 3 call centers, that the provider with 3 must be more interested in taking care of the their patients, and might even be better at PRM.  I don’t support that belief. I think it can be demonstrated that the provider with the most call centers, and most Patient Service Representatives, and the most toys deployed probably has the most problems with their patients. I don’t think it’s a chicken and egg argument. If expenditures increase year after year, and resources are deployed continuously to solve the same types of problems, I think it’s a sign that the provider and its patients are growing more and more dysfunctional.

How does this tie to Einstein and his boat? Perhaps the Einsteins are those who work with the provider; those who are moving at the same speed, those in lockstep. From their vantage point, the waves and the boat, like the provider and its patients, are all moving forward at the same speed. Perhaps only the people standing along the shore are able to see what is actually occurring; the waves distance themselves from the boat in much the same way that the patients distance themselves from the provider.

PRM is such an easy way to see large improvements accrue to the provider, especially using social media.

How to stop throwing away money on charts

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I sometimes need to rewrite ideas to help me get a better grasp of them—this is one of those times.  Too many words mean I still have too much chaff blowing around in my wheat.

More often than not I find it helpful instead to reframe the idea into an analogy.  I hope this is one of those times.

The idea I, and I think one which others are struggling, is where should physicians—hospitals, clinics, and practices—be looking to see benefits from their EHR, and I think part of the answer is that we may be looking in the wrong place.

Now, if your practice is running like a well-oiled business, this piece will not add another arrow to your quiver.  But, if your practice is like many I’ve seen, there may be an ah-ha moment forthcoming.  Most practices, rightly or wrongly, have been told to look for EHR benefits in the exam room.  While I think those benefits exist, if the rest of the practice—everything that happens between you and your staff, and your staff and your patients—resembles the chaos of an elementary school cafeteria giving away free ice cream, the clinical benefits may be hidden beneath the detritus of discarded creamsicle wrappers.

What if we look at the issue this way?  I was asked to paint the metal security door which leads from our laundry room to the garage.  The dogs had taken it down to bare metal.  In my small mind this should have been a thirty minute task.  Not so fast Sparky.

I went to the basement where twenty separate buckets of leftover paint are stored.  Found the white paint, grabbed my brush, gave the can a quick shake, and was ready to knock this out before my wife returned home.  In walked my supervisor—I was exactly 29 minutes too late.

“Don’t you need to wash the door before you paint it?  It is all rough where the dogs scratched it.  If you don’t sand it, we will still see the scratches.  You can’t use that paint; that is for wood and it won’t stick as well.  I printed these instructions from Google,” she said as she handed them to me—I was too busy watching my weekend disappear before my eyes.  “It says for painting metal you have to prime use a primer.”

My perspective on doing projects, for what it is worth, you can either tell me to do something, or you can tell me how to do it, but you cannot do both.  As I drove clear across town to the paint store I realized she’s never allowed herself to be distracted by my perspective.

Two hours after I had started the project the door was sanded and washed.  An hour later the primer had dried enough that I could apply the final coat of paint.

“What are all those white drops on the wood floor?”  We both knew she was being rhetorical, but waxing on about rhetoric was not the point of here question.  “The directions say you should be using a drop-cloth, and should clean up the paint spatters with a clean cloth and soapy water.”  Now why didn’t I think of that?  The truth is, I did, but each of those steps looked like they would only lengthen the task.

Five hours after beginning the quest for her holy grail, the door was painted, the splatters were no more, the brushes were cleaned, and the paint cans were stored neatly in the basement.  What I realized is that between starting the painting and completing the painting, many other tasks had to be completed that involved much more of my time than the actual process of painting the door.

During the five hours I spent on the project, only 30 minutes of my time was spent applying the finish coat—10 percent of the total time.

It makes the process appear a lot shorter if all one does is focus on one piece of it.  The whole issue of an EHR’s impact on your charting processes looks a lot shorter if one’s only focus is what happens to the chart from the time the physician pulls it from the holder on the back of the door to the time it is replaced.  In some practices more than a dozen people may be involved in getting it to the door and returning it to the file room.  What happens to the chart in the exam room is only a very small fraction of the cost of using paper charts.

It is less expensive to toss $100 bills out of the car than to fund paper charts.

At the end of this piece is a list of some of the chart handling processes I have seen at some of my clients.  In some places, there are many more processes than just the ones listed.  The average handle time (AHT) for a chart begins the moment a chart is requested, and it does not end until the chart is returned to its proper place on the shelf.  Any steps that can be taken to eliminate some or all of these processes, and the cost of the people who perform them, will contribute to the ROI of an EHR implementation.  In many cases, eliminating the majority of these steps will constitute the bulk of the EHR’s ROI.

From the perspective of the business, any time you can get rid of a process whose only contribution to the P&L is a cost, do so.  Having someone carry a chart, insert papers into it, or file it does nothing to improve care, and it does not contribute a dollar to revenue.  Eliminating these processes will make the business function better.  It will enable the business to handle growth.  None of what you’ve just read has anything to do with meeting Meaningful Use or having a certified system.

In the interest of full disclosure, I actually painted the door while my wife was out of town.  It took me thirty minutes, just like it should have—don’t tell her.

Here the list of the manual charting processes that increase AHT, and add no measurable value to your business.  They are workarounds, and should be eliminated.  A similar argument can be made for dealing with in-bound phone calls, but we’ll save that for the next time I have to paint something.

  • Old charts are ordered from archives
  • Loose sheets received daily at chart room from offices
  • Loose sheets are received from labs
  • Loose sheets are sorted by doctor and then either alphabetically or by date
  • Loose sheets distributed to clerk serving the particular doctor
  • Clerk pulls charts that have loose sheets to be filed
  • Clerk inserts chart out card as a place holder
  • Loose sheets will be filed to charts stored in chart room
  • Clerk hole punches loose sheets
  • Clerk returns chart to shelf and removes “out card”
  • Clerk crosses out his/her name
  • Charts arrive from archives storage to the chart room
  • Charts are sent to offices by courier
  • Charts are returned from offices to chart room by courier
  • Charts sent between offices by courier
  • Charts returned to archive by courier
  • Patient schedule is generated
  • New schedule compared to schedule generated yesterday to determine add-ons
  • Clerks determine which patients have no charts at chart room
  • Clerks determine which missing charts are at archive
  • chart room makes temp chart for add-ons; patients who were added to schedule after cut-off
  • Schedules needed are distributed to clerks that serve specific doctors
  • Charts on the schedule are pulled from chart room shelves by clerks
  • Clerk writes their name and date on out card indicating they have the chart
  • Out card is inserted as a placeholder
  • If chart is not found, clerk checks out-card to determine who last had the chart
  • Clerk tries to locate the chart
  • If chart is located, a request is made to send it to the correct office
  • If chart is not located, clerk creates a temp chart
  • Clerk adds note to temp chart explaining why she created a temp chart
  • Clerks match loose sheets against charts, punch and insert them
  • Additional forms may be added by clerk to chart
  • That chart is inserted into the box to be sent to the doctor
  • Boxes of charts returned from offices are distributed to clerks to be re-filed
  • These charts are returned to shelves, out card is removed
  • Clerk crosses off his/her name
  • chart room receives fax requests for charts
  • Those requests are delivered to the assigned clerk
  • Clerk repeats the chart hunt and pull process

Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

EHR ROI: a case study

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I recently heard an interview of John Cougar Melencamp during which he discussed what it was like writing a song to be used by Chevy.  The song, Our Country, proved to be one of his most successful commercial ventures.  The interviewer asked him what it was like having Chevy as a record producer.  To me, his answer was filled with meaning.  Melencamp answered, “Chevy was a better record producer than Columbia ever was.”  When asked why he said, “When they said they were going to do something, they did it.”

From what I’ve seen, that statement underscores the difference between EHR that portend to meet Meaningful Use and Certification, and the small handful that actually deliver an ROI to your business.

Let me present you with a real-life example, an EHR ROI case study.  The data shown on these graphs is real.  It was developed by analyzing how many times a certain provider moves patient charts.  It starts at the chart room, is touched many times until it gets to the doctor, and is touched many more times prior to being refiled.  Charts are handled more than fifteen discrete times and undergo more than fifty unique manual processes.

This chart shows the 5-year cumulative cost benefit of implementing the specific EHR.  It does so by calculating costs around the Average Handle Time (AHT) of each time the chart is touched.  To reinforce the point, AHT per touch was calculated at 3 minutes, 2 minutes, and 1 minute.  AHT also includes spent time walking around; to the printers, the copiers, the scanners.  To the chart racks, back to the desk, to another clerk.

The interesting thing about walking time, and AHT, is the clerks are being paid to exercise even though their walking and copying do not add any value to the patient’s chart.  That’s where the ROI lays.  Without a good EHR—one that creates savings—your business costs are overstated by having a dozen or more people sitting, standing, walking, talking, copying, filing, processing, two-hole punching, stacking, inserting, writing notes, and refiling.  What happens to all of those ‘ing’activities if you install a good EHR?  All of the value from those activities still takes place, but it occurs in a fraction of a second.  It appears on your screen in much the same way that 60 Minutes is plucked off a satellite and appears on your television.

The purple line shows the total five-year cumulative cost of implementing this EHR.  The vertical axis shows dollars.

There used to be a management style practiced by Ivy-League MBAs called Management by Walking Around (MBWA).  A good EHR is like being able to multiply MBWA by negative one.  It cancels out all of the walking and all the other ‘ing’ activities that incur costs without adding value.

If a Certified system is so special, offer a certification warranty

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I think that certifying the EHR product prior to installing it is worthless. Certification to me means that the product is capable of performing some function.   If certification is of any value, the fact that it’s certified means it should still be certifiable after it’s installed.

We all know that that is not the case. If the feds think it’s so important to certify the EHR products, let’s certify them after installation.   The large vendors are the ones pushing certification.  They do it for one reason, to limit competition.  If the vendors think certification somehow implies that their product is somehow better because it has been certified, let them offer a cost free warranty and re-certify it after installation.

It’s an easy test.  Let’s see how many of them respond to this plan.

We made it to the bigs

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Somehow, my social media article healthsystemcio.com made the top story of Chime Healthcare CIO SmartBrief.  http://ow.ly/2snrU

Not bad for a metaphorical tomato thrower.

Thanks for playing along.

Expert: Providers must make IT investments on their own, have new implementation strategies

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Here is the link to an article in HealthcareITNews that quotes a few of the things we have been discussing on this site.

http://www.healthcareitnews.com/news/expert-providers-must-make-it-investments-their-own-have-new-implementation-strategies

Will the ARRA money be worth the effort?

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According to the just released McKinsey study, the time has come for healthcare providers to set up a lemonade stand. Why? Because their findings indicate that the incentive money available to doctors may only offset about twenty percent of the costs of implementing EHR. You can read their analysis here:

http://www.mckinseyquarterly.com/Health_Care/Strategy_Analysis/Reforming_hospitals_with_IT_investment_2653

I disagree with a few of the comments in the McKinsey paper. First, the paper begins with two comments, neither of which is accurate; “Mandated upgrades to healthcare IT…”, and “New regulations require…” Lest we forget, having an EHR is optional—choosing not to have one is probably not a smart business decision, but the decision is yours, not Washington’s. Meeting Meaningful Use is also optional. Regarding Meaningful Use, I think an argument can be made that providers are better off without it—you can read my reasoning in some of my prior posts.

So, ARRA money will only meet 20% of your EHR costs. This should not be a news flash. In fact, I think that for more than half of the providers, the ARRA money will not even cover the additional costs of meeting Meaningful Use, let alone the costs of implementing the EHR.

So, if you are seeking an ROI over the total cost of the EHR, and not simply an incentive payment to cover the cost of a gross of “EHR—Yes we can” t-shirts, what can you do?

Sometimes the simple answer is the best answer. I think the answer to this question is quite simple, and its simplicity is what makes it achievable. It is not an answer being looked at by many providers. Approach your EHR implementation as though Meaningful Use did not exist.

Too many providers set the goal of their EHR as completing the implementation. “They wanted an EHR and we gave them an EHR.” This passes neither the test of being necessary or sufficient.

What are your business goals for your EHR? I suggest two:

• Be more efficient

• Be more effective

If your EHR can help you do these two things, you will meet the other goals, goals like providing better care, reducing the number of errors, saving time, and eliminating processes that add not value. Therein lays the all too elusive ROI.

There is actually another way to get money for an EHR that functions well. Once the EHR is running, there is a huge volume of digital data throughout the organization that can be aggregated. The Blues (Cross and Shield, not Belushi and Aykroyd) offer money back to healthcare providers who are able to demonstrate that they have saved the Blues money. If providers prescribe generic medications, naturally it costs the Blues less money. The Blues will share their savings with the providers. The way a provider can capture those funds is to have an EHR that is capable of reporting the generic meds it prescribes to the payor.

It is worth a phone call to your EHR vendor to find out if your system can do that. If not, the best fall-back position could be the lemonade stand.