EHR’s: COWs, WOWs, and Flashlights

Timing is everything. In the case of EHR, timing, Apple’s timing for bringing the iPad to market, was three to five years too late. 

That is why hospitals spent millions on hard-wiring computers into patients’ rooms and nurses’ stations.  Would’a, could’a, should’a gone wireless.  But no one knew.  Hospitals were not prescient enough to have gone wireless in the middle of the prior decade as everyone still thought wireless technology was a canard.  Nobody even knew what an app was, let alone that an app for a user interface to the EHR could be run off of a tablet.

That is why most EHR desktops are hardwired to a wall.  And which wall is it?  It is usually the wall across from the foot of the patient’s bed, the one furthest from the patient, the wall that requires the healthcare professional (HCP) to turn away from the patient to be able to enter data.

Suppose for a moment your organization decided to learn just how effective was the investment in the hundred-million dollar EHR.  One way to do this is to audit some number of health records to investigate whether or not the data for the patient record is and complete valid.  That approach will provide you with a modicum of what you need to know.  That answers the question, is the EHR being used?

Valid data does not answer the following questions:

·       Who input the data

·       Was it input in real-time while the HCP was with the patient or was it input at the end of rounds?

·       Did the HCP use paper and pen to record data

·       Was non real-time input done from the information on the HCP’s paper? In other words was the data captured twice?

·       If the data was captured twice, are both instances of the data correct?  Which patient record is the record of record; the paper or the EMR?

·       Have each of the various stakeholders—nurses, therapists, physicians—developed their own way of using/not using the EHR?

·       Do they each have their own workarounds?

Here are some recent actual observations about the use of the EHR at a large hospital:

·       Most of the patient data is entered at the end of the HCP’s rounds.

·       Data is entered on a large number of manual forms

·       The data on the forms does not match the data required on the EHR screens

·       The forms do not match the screens

·       Data is pushed from the forms to the EHR

·       Hospital exams are recorded on paper

·       Charting while on rounds meant the HCP was only able to cover 2/3 of their patient load

·       HCPs had to login to the computer and to the EHR dozens of times to complete their rounds

Here is my favorite observation gleaned from shadowing the HCPs—the EHR is used as a flashlight.  HCPs stand next to the EHR screen and use the light emitted from the screen to help them see to write their notes on paper.

The items referenced above illustrate ineffectiveness and inefficiency.  Duplication of data, duplication of work. These will lead to errors and a loss in productivity.  The good news though is that the hospital now has several hundred large flashlights.

Also observed were COWs and WOWs with EHRs—Carts On Wheels and Workstations On Wheels.  It just goes to show you that you can learn something new every day.

Video Game Theory applied to Healthcare IT

My twelve-year-old son overheard a conversation I was having about EHR, Meaningful Use, and ICD-10, and I watched his eyes glaze over.  So I tried to explain it to him in terms I thought he might understand.  Maybe this explanation is the one I should have used with my client.

John and Sally have a thousand dollars in the bank.  They pool some of their money and have a hundred dollars to spend on video games.  The game they really want, Project From Hell, costs sixty dollars.  About half the people who play Project From Hell never make it to the end, and never get the chance to claim their prize.  It takes two years to play, and one or both of them could be eliminated from the game for failing to play well.

The second game is a take-off on Faust, Sell Your Soul to the Devil.  To play this game, you must first beat Project From HellSell Your Soul costs thirty dollars.  However, the upside is that if you win, which is not very likely, you can earn two dollars.

The third game, Bet Your Savings, is the most intriguing.  All kids who have a computer must play Bet Your Savings, which costs thirty-five dollars.  The way Bet Your Savings works is that if you do not play, or if you play and lose, ten percent of the money in your bank account disappears.

I asked my son which games John and Sally should buy.  He said if they bought Project From Hell and Sell Your Soul, they would only have ten dollars left, and that the reward from Sell Your Soul, two dollars, was not worth much.  He also noted they do not have enough money to buy all three, and that since Bet Your Savings was mandatory, unless John and Sally wanted to automatically lose ten percent of their savings, they must choose Bet Your Savings.

He decided they should buy Project From Hell and Bet Your Savings.

By now you have figured out the Project from Hell is your EHR, Sell Your Soul is Meaningful Use, and Bet Your Savings is your ICD-10 initiative.

Resources are scarce.  Do you have enough money to do Meaningful Use and ICD-10 correctly?  Many hospitals do not, and yet they are charging full tilt at meeting Meaningful Use to possibly net a few dollars.  Many hospitals have not invested enough to meet ICD-10.

Where should you place your limited resources?  If you are still confused, feel free to ask my son.

Why bother with an RFP for EHR?

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

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

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

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

Patient Relationship Management (PRM)

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

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

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

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

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

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

How to stop throwing away money on charts

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

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

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

Will the ARRA money be worth the effort?

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

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

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

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

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

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

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

• Be more efficient

• Be more effective

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

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

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