This link will take you to a slideshare,net presentation that defines how healthcare providers can take control of the EHR project. I welcome your comments.
http://www.slideshare.net/paulroemer/the-users-role-in-ehr
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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.
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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.
Paul M. Roemer1475 Luna Drive, Downingtown, PA 19335
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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:
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?
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The two groups are often far apart.
I learned an interesting word which led to some very interesting reading on the topic. The word and topic are qualia (pl). There are several wordy explanations with which I won’t waste your time.
Daniel Dennett identified four properties that are commonly ascribed to qualia. According to him, qualia are:
Got it? That didn’t do it for me either. Here are a few examples that helped me understand it.
Common things. Our brain knows what they are, yet to describe them to someone who has not experienced them, almost indescribable. Your brain processes it one way, your mind processes it another. Take a look at these pictures.
Now let’s look at healthcare IT projects, to be more particular, implementing an electronic health records system, an EHR system. When you pictured the implementation in your mind, when you studied the implementation plan it painted a nice picture. All the pieces made sense—sort of like the picture on the left.
At some point after most EHR implementations, the IT department still sees a pony. The users can’t see the pretty picture. Trying to explain what went wrong to the steering committee is like trying to describe to them the color blue.
IT people are able to look at the picture on the left and visualize the picture on the right. When IT people talk to users, to the users it sounds like the picture on the left…
…and it feels like this.
It matters what the users think, and see, and feel. If IT waits until the end to involve the users, the users will never see a pretty picture. I’ll let you in on a secret. In many hospitals the users (doctors and nurses) do not think IT has any understanding of their business. Why prove them correct by keeping them out of the loop. Their input is at least as important as IT’s and the vendor’s—probably more so.
“Look what we built for you” is not what the users need to hear. “Look what we did together” has a much better chance of succeeding.
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Several years ago I was invited to go on the ultimate boys’ toys, weekend getaway. A dozen of us flew from Denver to Utah, and then drove to a point somewhere west of Bozeman Montana. It was to be a weekend of sport, a weekend of competition, and a more than occasional libation. To say that the people who organized the trip came from money would be a major understatement. They were in the oil bid’ ness. The father of one of the guys was the CEO of the second or third largest petroleum company in North America. We stayed at his ranch, a 12 bedroom log cabin in the middle of Nowhere, Montana, which is about 20 miles west of Next to Nowhere, Montana.
The weekend’s activities included fly fishing, duck hunting, and Gin Rummy. Each participant was given a handicap rating in each event. The idea behind the rating was that if you are weak in one event, you were paired with an individual who is skilled in that event. In theory, that would level the playing field among the teams. Since I have never fly-fished or hunted I was odd man out. But I was game, and it’s amazing how good one can become at something when one has to fight their way through it.
Let the games begin. We started the competition with a full day of fly-fishing. Our destination was the Madison River, an impressive, fast running, expanse of snow melt. The stretch we would finish was about 150 feet wide, and its average depth was somewhere between waist and chest high. As I would soon learn the bottom was covered with what appeared to be the equivalent of moss covered bowling balls. I was instructed by one of the more experienced fishermen to tie a nymph to the end of the tippet. For those of you who are as novice to the sport as I was, a nymph is an artificial lure which mimics an insect larva. It is designed to lure fish who feed along the bottom, not the nubile young woman referenced in Greek mythology.
We fished for several hours. My legs ached from trying to maintain my balance in the strong current. I was about ready to admit defeat when the tip of my rod bent sharply into the water. Standing perpendicular to the current, I could see as the brightly speckled back of a large rainbow trout turned upstream. Naturally, I turned upstream with it and began to try to reel him in. First mistake. It was at that point that I first realized that the height of the water was now about level with my chest waders. Second mistake. The guys on the other part of the river and along the bank were yelling at me. I thought it was words of encouragement. Final mistake. As it turns out, they were trying to convince me not to turn upstream. At the exact moment that I faced stream head on, was the exact moment my feet lost purchase with those moss covered bowling balls of which I wrote. Turning yet again to my physics, I quickly recalled the equation; force equals mass times acceleration. Instantaneously, I was swept downstream, still clutching my fly rod in my right hand.
Wayne Newton’s first law of fluid mechanics took over; waders, no matter how good they are, if positioned in a plane that is horizontal to the river will fill rapidly with water, just as mine did. The choice with which I was faced was do I save myself and lose the fish, or do I try and land the fish? One of the shortcomings of maleness—I was going to use maledom until I Googled it—is that we rarely have actual choices, especially when we are around other males or for that matter, females. Naturally, I opted to land the fish. My reel had become dislocated from my rod. I remember grabbing the reel and stuffing it down my waders, and as I tried to float my body as though it was a raft without a rudder towards the river’s nearest bank, I began to reel in the monofilament with a hand over hand motion. After several minutes I was standing dripping wet and proudly displaying a 19 inch rainbow trout.
We cooked the fish and played Rummy until about three in the morning, awoke at four, grabbed our shotguns and headed out into the darkness without so much as a cup of coffee. Round three of the competition was to be duck hunting. To this day I’m still unclear as to why we had to hunt ducks while it was still dark. Weren’t there any ducks who needed shooting at brunch time, I inquired? Twelve guys, who collectively smelled like a distillery, and who are operating on an hour of sleep, armed with loaded shotguns, trod through a willow thicket as dawn approached. As I neared the river bank, a startled duck shot skyward. I raised my over and under twelve-gauge shotgun, sort of took aim, and fired a volley. The duck seemed to pause in midair, and then fell like a rock into the racing water. I watched helplessly as my quarry floated away from me. I looked downstream and was pleased to see two men fishing from a rowboat. The duck floated right towards them. A man reached down, retrieved my duck, and dropped it in his boat. He then waved to me. Thinking he was being friendly I returned his wave. He then rowed away with my duck.
It was a great three days. Part of what made the weekend fun with not having to excel at each event. It helped knowing that in areas where my skills were not as good, I could count on the skills of others and vice versa. The idea behind this approach was to build competitive and level teams. That approach works well in mano y mano events like those I described. It works much less well in EHR, HIT and healthcare reform in general. I’m trying to recall if I wrote previsouly about a meeting I attended with a former hospital CEO. His take on EHR was the total inability of his peers to have any precience regarding their approach to EHR. According to him, very intelligent people were making very unintelligent decisions, committing their entire institution to strategies made with almost no data. Some people can give a better explanation for why they bought their car than they can for why they selected their EHR. That’s the wrong way to handicap this event.
There are two ways to handicap your EHR. One way is to look at the program from the perspective of risk assessment and assess–handicap–the risks. The other way to to be a detriment to the program’s success. One of these is bad.
Paul M. Roemer1475 Luna Drive, Downingtown, PA 19335
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I started a Google Wave whose purpose is to see if you will share your thoughts about when push comes to shove, does the success or failure of an EHR have much to do with what system you select as long as you select one of the top 5-7?
I think it can be argued that if you select from among the top vendors by placing their names in a hat and drawing one, you do not lessen your chances of being successful.
What’s your take? Please invite others to participate.
Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy
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Sometimes I feel a little like the ambassador from the planet Common Sense, and unfortunately very few of us speak the same language. Let’s see if we can segment the Patient Relationship Management (PRM) population into left brainers, and right brainers. I am wrestling with an issue that I believe is a no-brainer.
One point, upon which both sides seem to agree, is that without the patients, PRM would be superfluous. The breakdown is that for a hospital to flourish in the long term, hospitals should re-engineer their business processes to facilitate the dissolution or substantive reduction of traditional customer service. This extends beyond the cordial relationship of a nurse or a doctor and their patients in hospital beds.
In many, if not most instances, the very existence of traditional customer service provides a vehicle which acts as an enabler for failure. It gives hospitals permission to be mediocre in dealing with their interactions with their patients and physicians. In effect, traditional customer service is a tacit admission to the employees and the patients, “We don’t always get it right. We don’t always do our best.
Before deciding not to read further, ask yourself a few questions. The purpose of the questions is to try and articulate a quantifiable business goal for customer service, PRM.
1. Does customer service have planned revenue targets
2. Does it have its own P&L?
3. Does it have a measurable ROI?
4. What is the loaded cost for each patient and doctor interaction?
5. Could the costs of those interactions be eliminated by fixing something in operations?
If the answers to 1-3 are no, the answer to 4 is unknown, and the answer to 5 is yes, your hospital inadvertently made the decision to ignore revenues and to incur expenses that provide no value to your organization. I believe this premise can be proved easily.
The careers of many people are directly tied to the need to have customer service and call centers. Big is good. Bigger is better. Software, hardware, telecommunications, networks—more is better. Calls are the lifeblood of every call center. Without those calls, the call center dies. Calls are good, more calls are better.
When was the last time you were in a meeting when someone said something like, “In the last three years our patient call volume has continued to increase,” or, “Calls have gone up by forty percent.” That part may sound familiar. The phrase nobody has heard is, “We can’t continue to add that many calls.” Tenure and capital. That part of the business is managed with the expectation that the number of calls will continue to grow. And guess what? It does. How prophetic is that? Or is it pathetic? You decide.
Given that, how does the typical healthcare provider manage their customer service investment? Play with the numbers. In many organizations, if customer service management can show that patient satisfaction is holding steady, no matter how bad it is, and they can use the numbers to show that some indicator has moved in a favorable direction, other areas of the business are led to believe that customer service is performing well.
Memo to those executives who are authorizing customer service expenditures—I want to make sure there is no mistaking how I view the issue. If that is what you are hearing from your customer service managers, they either don’t understand their responsibility, or they understand it and they don’t want you to understand it.
To be generous, if patient satisfaction with regard to customer service is below ninety-five percent, your customer service is in serious need of a re-think. Just because patient satisfaction is not tanking faster does not mean customer service is functional.
Most executives know how to get numbers to paint whatever picture they need to paint. Beware the sleight of hand. Any time the customer service manager comes to you and says he is improving operations by reducing the average amount of time someone spends on the phone talking to a patient (average handle time), don’t believe anything else he tells you. Allow me to translate. When the customer service budget is tight (too many interactions and too few people with which to interact) the way to make it fit the budget is to make your people end the call quicker. Shorter calls mean more calls per hour. Note—speed buys you nothing, except for more repeat calls, less resolution, less patient satisfaction. It’s a measure of speed—IT IS NOT A MEASURE OF ACCOMPLISHMNET.
I’d be willing to bet that somewhere between twenty-five and fifty percent of calls from your patients and physicians can be addressed better via a combination of social media and the Internet.
Paul M. Roemer1475 Luna Drive, Downingtown, PA 19335
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…but I inadvertently just proved my own point, albeit to myself. I have been fooling around–with my old MP3 player, and I couldn’t get it to turn off or on–that’s why my wife hides the power tools.
I ducked into a nearby phone booth and put on my SSCC (self-service customer care shirt)–do you realize most kids under the age of ten have never seen a phone booth? Sorry.
Off to Google. I never even considered going to the manufacturer’s web site. I typed, “Remove battery from Creative Vision:M.” Up pop several YouTube videos, each done by one of Creative’s customers, showing step-by-step with voice instructions explaining how to correctly remove the battery. I place a lot more faith in what a customer tells me than I do in what they firm tells me. Your customers (patients and doctors) do the same thing.
The user manual that came with the device never mentions how to remove the battery.
And this is my point. Your patients know what your other patients need, and in what form it will be most useful. And, they are providing it. Now, how difficult would it be for a hospital, say your hospital, to start thinking about your patients as though you were a patient? Not very.
Of the few hospitals which have a Patient Relationship Management (PRM) strategy or social media (SM) strategy, not too many are effective. I’ve only seen one which uses those to increase revenues. Most hospitals use PRM and SM to manage spin, to try to counteract what their patients are saying about them. One can only imagine the impact a hospital could have by starting the spin, starting conversations about itself using these tools.
You know what? You don’t have to imagine it. It is probably the easiest project you will undertake.
Here’s a link to a PowerPoint deck on the subject of PRM.
http://www.slideshare.net/paulroemer/good-CEM-deck
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Success and failure are often separated by the slimmest of margins. To succeed, sometimes you have to be prepared to think on your feet. You have to outthink unfavorable circumstances. Often, success or failure hinges on how you present an idea.
Permit me to illustrate with frozen chicken. Several hours before dinner I threw some 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 was correct. Noah would already have been building an ark. Grabbing every towel I could find, I sopped the puddles from the hardwood floor. While mopping I thought about how I might answer my wife if she returned to a kitchen that looked like Water World. My first instinct, admittedly poor, was to tell her 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 were removed, and believing the major threat from her had passed, my wits slowly returned. I worked on version two of the story—how do I explain all the wet towels. I arrived quickly at a more believable version of the truth—I would tell her I decided to wash the towels—all of them. Why not get bonus points instead of getting in trouble?
Version three sounded even better. Since I’d wiped the floor with the towels, instead of simply telling her I washed the towels, why not double the bonus points? I’d tell her I washed the floor, and washed the towels. Husband of the year can’t be far off.
A few hours have passed since the indoor flood. 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 and deft presentation.
Back to healthcare. A few of you have written and asked, how do you propose we turn around our EHR implementation, turn the focus to solving business problems, not simply implementing an unwieldy system simply to collect the ARRA ransom money?
All kidding aside, it comes down to presentation. Clearly you can’t walk into a steering committee meeting with a just a slide deck showing that the current EHR implementation strategy will decrease productivity. If there are problems with what you are doing, or the support you are receiving, or the immediacy with which the committee wants to the project to end, present the consequences of the action. Then present what could be accomplished and what you need to make it happen. EHR is not done just because the vendor is no longer in the building. All you can conclude from that is that there are a few freed up parking spaces. Your goose may be cooked.
So, what happened with my chicken dinner? I was confident I had sidestepped to worst of the threat. Overconfident, as it turned out. My son hollered from the basement, “Dad, why is all this water down here?”
Pale Rhino Consulting 