Published on–vendor darts

Below is the full article I submitted to, 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,  However, the names of the modules rated are vendor specific, and none of the vendors use the same names.  It will give you a feel for how a small sample rated features within a given vendor, but there is no data to suggest how those ratings compare among vendors.

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

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

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

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

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

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

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

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

Simply put—the problem is not the EHR system.

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

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

What is the cost of EHR 2.0 not working?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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

Users are from Mercury, IT is from Pluto

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:

  1. ineffable—they cannot be communicated, or apprehended by any other means than direct experience—see, touch, taste, hear, smell.
  2. intrinsic—they are what they are independent of anything else.
  3. private—interpersonal comparisons of qualia are impossible.
  4. directly or immediately apprehensible in consciousness—to experience a quale is to know one and to know all there is to know about that quale.

Got it?  That didn’t do it for me either.  Here are a few examples that helped me understand it.

  • How does wet feel?
  • What does blue look like?
  • What is the smell of mowed grass?
  • How does salt taste?
  • What is the sound of a whisper?

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.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 85-6942

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

Your EHR contract–Until death do us part?

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

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

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

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

Manage it till death you part?

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

From now until death do us part,

And I will manage it when it breaks,

And when my boss over the coals me rakes,

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

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

And we will own it when it’s bad,

And we will own it when I’m mad,

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

When all our patients want me to choke,

And when if fails Meaningful Use,

And when its failure cooks my goose,

And I will be none the dapper,

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

While searching the bowels for our old charts,

Since productivity has fallen apart,

I will manage it as you like,

As all our doctors go on strike,

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

Comparing EHRs–like measuring how wet is water

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

EMR Key Differentiators.

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

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

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

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

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

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

A scathing rebuke of EHR

I encourage anyone with an EHR or thinking of getting an EHR to read this.  I do not think it is a unique story.

I recently spent an hour with my cardiologist.  He is employed by a very large teaching hospital.  After checking my vitals, listening to my heart, and asking a few questions, he moved from the exam table to the keyboard—where he remained.


The focus of our conversation quickly moved away from me and onto him—more accurately to his Hospital’s three-year-old EHR system.  I learned quickly from him that calling it a system was somewhat optimistic.

Here is what I learned from him about the hospital’s EHR:

  • It is possible to take your most expensive and most trained resource away from what they do and have them spend forty-five minutes of the hour performing a clerical task—data entry.
  • Productivity is down at least thirty percent.
  • He called EHR the “Silent intruder in the room.”
  • “What are the benefits?” I asked.  “It does a great job collecting data for those who may want to use it against us in a law suit.”
  • “What about interoperability?”  “Not in my lifetime,” he replied.
  • “It makes everyone’s job easier but mine and the nurses.”
  • “Did anyone speak to you about what you needed from an EHR?”  He is still laughing.
  • He needed his nurse to help him schedule my next appointment.
  • “How would you react if I asked if what the hospital implemented was nothing more than a hundred million dollar scanner?”  “I would not disagree with that assessment.”

The good news is that he is arranging a meeting for me with the hospital’s CEO to see what I can do to help.

My take?  I was the other intruder in the room.  

AN EHR introspective–my cardiologist and me

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

EHR: How do you avoid failing?


I may have mentioned that I’m a runner. In high school and college I’d run anytime, anywhere. I ran cross country, indoor track, outdoor track, and AAU– kept my hair tied back in a ponytail—I miss the hair.

Those were the days. I was the captain of the cross-country team during my senior year. Behind the school was a long series of hills we used for training, and they were blocked from the coach’s view. I remember that one day I told the team it was okay to walk because we were out of the coach’s sight. I also remember when he took me aside after practice and said he didn’t think it was a good idea for the captain to tell the guys they could walk. He said he couldn’t see me but he sure could hear me. I also remember the time I had my mom dropped me off about half mile away from my girlfriend’s house so I could run, making it look like I ran the entire six miles.

My friends and I ran a few 50 mile races and a couple of marathons. But the strangest race we ever ran was one that lasted 24 hours. The event was a 24 hour mile relay. More than a dozen teams entered the event. Our team had seven runners. The idea behind the race was that each person would run around the track four times with a baton and then hand the baton to the next member of his team. If one member of the team was too tired to take his turn, that team was disqualified. The race started early on a Saturday morning. At the end of 24 hours, my team had run 234 miles. We were proud of what we had done. We were even prouder when we saw the article printed in our local paper the following week that we had set a world record for a seven-man team in a 24-hour relay.

I’d like to believe that the world record had something to do with the fact that we were a great group of runners. However, as I look back on it I tend to believe that the world record had more to do with the obscurity of the event than with the capability of the runners. I don’t know if that same event had been run before we ran it or was ever run afterwards. Who knows, we may still hold the record. I guess what I learned from that event, is that it is easier to be viewed as being excellent at something that isn’t done very often.  Obscure or not, it was a one-time event for us.

Doing something once makes it difficult if not impossible to prepare for the gotchas that lay in wait.  There are healthcare providers who are on their second and third attempt at implementing their electronic health records system (EHR).  This is not the type of event where practice makes perfect, far from it.  If you don’t get it right the first time, you’ve probably already laid waste to your most important stakeholders, the users.  They are difficult enough to get on board the first time.  The second time it becomes much more of a fool me once shame on me, fool me twice, shame on you.

How do you avoid second and third attempts of something as difficult as a full-blown EHR?  For some providers, it’s even worse in that they probably have multiple dissimilar instances of EHR already in place in parts of the hospital, instances that will have to be integrated to the corporate platform.  If you let the clinical side run the project, you run the risk of losing the IT side.  If you let the IT side run the project, you run the risk of losing the clinical side.

Who do you trust to run what could amount to a few hundred million dollar project, bring out the best skills of the team members, and make sure the vendor is operating in your best interest?  It’s a difficult question to answer.  The good news is that if you get it wrong you probably won’t have to worry about doing it over, that will probably be your one-time event.