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.


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

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.