How to stop throwing away money on charts

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 M. Roemer
Managing Partner, Healthcare IT Strategy

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

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

Where workflow goes to die

There are two types of business processes; easily repeatable processes (ERP), and Barely repeatable processes.   Most of the real work that needs to be done in EHR workflow improvement happens in the blank white space between the boxes on the org chart.  That’s where you’ll find a lot of the BRPs–Barely Repeatable Processes.

It is easy to automate the ERPs, and nearly impossible to automate the BRPs.  If you can’t reform either set of processes with your EHR all you have implemented is a very expensive chart scanner.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

Revising your work flows?

revised work flowAs a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

“Who moved my cheese?”

Sometimes you find something that is too good to mess with.  The following comes from “Who Moved My Cheese” by Spenser Johnson.  It is the perfect allegory for healthcare.
Change Happens
They Keep Moving The Cheese
Anticipate Change
Get Ready For The Cheese To Move
Monitor Change
Smell The Cheese Often So You Know When It Is Getting Old
Adapt To Change Quickly
The Quicker You Let Go Of Old Cheese, The Sooner You Can Enjoy New Cheese
Move With The Cheese
Enjoy Change!
Savor The Adventure And Enjoy The Taste Of New Cheese!
Be Ready To Change Quickly And Enjoy It Again & Again
They Keep Moving The Cheese.
saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

The change keeps changing

Hello to those whom I’ve yet to meet.  This is rather long, so you may wish to grab a sandwich.

I write to share a few thoughts.  I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.

Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there.  Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT.  They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform.  I somewhat disagree with that perspective.

Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them.  Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.

Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.)  The carrot?  The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.

Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works.  Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing.  Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot.  I’d staff with a heavy emphasis on the following subject matter experts:

• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing

Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN.  Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.

Interoperability, cost, and the lack of standardization will force a different solution—one which is portable.  I think the solution will have to be something along the lines of a single, national, open, browser-based EHR.  It will be driven by consumers.  Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.

The Personal Health (PRH) will have evolved to become the EMR.  How is this possible?  What do smart devices do?  They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros.  That is what today’s EMR are—ones and zeroes.  Those next-gen devices will be EMR-capable.  Why?  Because there are more than a hundred million customers who will keep buying these devices.

The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.

Firms like Apple, Google, and Microsoft will drive this change.  We already buy everything they offer, in fact, we line up at midnight to do so.  By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data.  Their current PHRs are their way of introducing themselves to consumers as players in healthcare.

The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown.  Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.

If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check?  That is the government’s home run.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

Should you listen to the voices in your head?

Well, for starters, if you don’t nobody else will.

Just because I’m paranoid, doesn’t mean the voices in my head aren’t real. What voices?  They don’t like it when I speak of them, so I am going to speak in parentheses so they do not hear me.)

Riding the in the car yesterday with my son, the radio was playing Barber’s adagio, a mournful and eerily melancholy piece. It has long been one of my favorites.  I tried to get my son to turn off his PSP long enough for him to try to develop an appreciation for it.

He asked me to tune the radio to what he calls ‘his’ station while I kept extolling the specific virtues of the adagio, of Barber, and of classical music in general. I intended to win him over to my way of thinking.

The phrases I used to bolster my opinion kept coming to me, although I knew not from where.  I soon reached the point where I knew that I was no longer speaking to him, but role playing the very same discussion I had had with my father when I was about the same age as my son. Déjà vu. I have become my father’s son. The voice in my head was my father’s and I was not even charging my father rent for the space.

Do you hear the voices? No, not those voices. The ones you hear at work when you realize that the person speaking to you is your other self. The same voice you hear when you go out after work with your friends and begin to talk shop. By the third glass of wine the conversation has shifted from swapping stories about the craziest patient to wondering aloud when the company is ever going to learn how to fix their business. By glass five, you’re fixing it for them, diagramming solutions on cocktail napkins.

A word of encouragement. Listen to the voices. I bet you’ve come up with some great ideas. They won’t do anyone any good locked up in your head. Let them out. Show someone who can do something about it what you wrote on the napkins.

Patient Relationship Management (PRM) – where to start






I was watching something on the Smithsonian channel and caught a clip of an interview by Gary Powers, Jr. He was discussing his father, and the interviewer asked him about his dad’s ill-fated U2 flight—Gary Powers’ spy plane was shot down over the Soviet Union in 1960 by a surface-to-air missile.

“I asked him how high he was flying when the missile hit his plane,” the son replied. “His answer was, ‘obviously not high enough’.”

Not high enough. A bit of an understatement. When you’re piloting the spy plane and you can see the SAM’s contrail you’re about to have a bad day. By the time you see the smoke streaking towards you it’s already too late. Would’a, should’a could’a don’t matter. At this point all you can do is make the best of a bad situation. The time to prevent the problem has passed; the only option left is to minimize the consequences.

I look at Patient Relationship Management (PRM) pretty much the same way. For the most part, by the time the phone rings, it’s already too late to have done what was required to have prevented the need for the call.  Would’a, should’a could’a don’t matter. At this point all your organization can do is make the best of the situation. The time to prevent the call has passed; the only option left is to respond to the caller’s request.

If your hospital or office is like most others, almost all of the attention and technology are focused at responding to the caller once the call’s been received, kind of like trying to put the toothpaste back into the tube.  There are very cost-effective ways to evaluate providing excellent PRM prior to having to do it via a call center.  Social media can play an important role.


Stilleto Change Management







I just returned from the Prada show in Milan. Not really—that was the opening line from a piece on NPR. Apparently this year’s runaway hit on the runways has to do with high heels, with the emphasis on the notion of high.

The following comes from the UK Telegraph: The girls looked like rabbits trapped in the headlights; their faces taut and unsmiling, their eyes wide with fear and apprehension. Were they about to undertake a parachute jump? Abseil down a 1,000ft mountain? None of the above. All they were doing was trying to negotiate the catwalk at Prada during this week’s Milan fashion shows in shoes that were virtually impossible to walk in. At least two models tripped and fell on to the concrete floor; others wobbled and stumbled, teetering and tottering, clearly in agony, and all the while their minds were fixated on just one thing: reaching the sanctuary and safety of the backstage area without suffering a similar fate.

According to the NPR reporter, the heels are so high that regular people—women people that is—can’t seem to walk in them without falling. This problem has led to the creation of an entirely new micro-industry. In L.A. and New York, there are classes to teach ladies how to walk in very high heels without hurting themselves. These classes are being offered through dance schools that couldn’t fill their dance classes—they are now booked solid.

Tell me this isn’t the same as trying to walk and chew gum at the same time. Multitasking. Now before I make fun of some thirty year-old that has to relearn how to walk, let us turn our attention back to those dancing—cum—walking schools. From a consultant’s perspective what makes this story interesting is that those businesses saw a need and re-engineered a part of their operation to meet that need, sort of like we’ve been discussing regarding the impact EHR and reform can have on your organization.  With the implementation of EHR, many things will change.  If they don’t require change, you probably wasted your money on the EHR.  What’s important is having a plan to define the change and manage it.  Rework work flows, remove duplicated processes and departments.

Now I’m going to go saw the heels off my wife’s shoes before she hurts herself.


EHR: there’s a difference between finished and done


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

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

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

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

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


Why is change management so important?

If  EHR is about anything it’s about change.  So much of what exists today has to do with creating and moving documents.  Did you know?

  • Of all documents handled each day in the average office,
    90% are merely shuffled
  • Currently, 90% of corporate memory exists on paper
  • There are over four trillion documents in the U.S. alone,
    growing at a rate of 22% per year
  • Professionals spend 5-15% of their time reading information,
    but they spend up to 50% looking for it
  • Corporate paper-based documents are growing at the rate of
    200% per year
  • 19 copies are made from each paper document
  • 22% of all documents are lost
  • 7.5% of paper documents are lost completely
  • 3% of the remainder get misfiled
  • $20.00 is spent on labor to file a document
  • $120.00 is spent on labor searching for the misfiled paper documents
  • $250.00 is spent on labor to search for lost files

From Price Waterhouse

black saint 2