EHR: when you are in a hole, stop digging

I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school.  The camp was for high school students of varying backgrounds and their counselors.  On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic.  No amount of talking was going to get her to move either up or down, so it was up to me to rescue her.  I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers.  Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us.  I remember that only after I locked her harness to mine did she begin to relax.  She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others.  He continues to struggle but can’t find a way out.  A CFO walks by.  When the man pleads for help the CFO writes a check and drops it in the hole.  A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want.  Where were we?  The vendor.  The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole.  “What are you doing there?”  I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole.  “Why did you do that?  Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving.  However, before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

Merely appointing someone to run your EHR effort doesn’t do anything other than add a name to an org char
Kind Regards,


Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

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

EHR Short Cuts

How able are you to conjure up your most brainless moment—don’t worry, we aren’t on the EHR part yet.

As I was running in San Diego I was passed by a harem of seals—Navy Seals.  Some of them were in better shape than me, I couldn’t judge the fitness of the others as they ran by me too fast.  That got me thinking.  For those who having been regular readers, you’ll know this is where I have a tendency to drive myself over a cliff.

Seeing the Seals took me back to my wistful days as a cadet at the US Air Force Academy.  Coincidentally, my hair looked then a lot like it looks now.  One of the many pastimes they tossed our way for their amusement and our survival was orienteering; sort of map reading on steroids.  One night they took us to the foothills of the Colorado Rockies, paired off the doolies, gave us a set of map coordinates, a compass, map, and flashlight.  The way training worked, those who proved to be the fastest at mastering skills fared better than those who weren’t.  Hence, there was plenty of incentive to outperform everyone; including getting yourself to believe you could do things better than you could, sort of a confidence building program.

We were deposited in a large copse—I’ve always liked that word—of trees—I don’t know, but it seems adding trees to the phrase is somewhat redundant.  We had to orient ourselves and then figure out how to get to five consecutive locations.  The sun had long since set as we made our way through the treed canyon and back up a steep ravine.  After some moments of searching we found the marker indicating we were at point Able.  The group started to examine the information that would direct our journey to point Bravo.

While they honed their skills, I was examining the map, taking some bearings with the compass, and trying to judge the terrain via the moonlight.  My roommate, a tall lanky kid from Dothan, Alabama asked why I didn’t appear to be helping.

“Look at this,” I replied.  “Do you see that light over there, just to the right of that bluff?  I think I’ve found us a shortcut.”

“What about it?”  Asked Dothan.

“If my calculations are correct, that light is about here,” I said and showed them on my map.  “It can’t be more than a hundred yards from point Delta.”


“So why go from Alpha to Bravo to Charlie to Delta, if we can go right to Delta from here?  That will knock off at least an hour.”  I had to show my calculations a few times to turn them into believers, but one by one they came aboard.  The moon disappeared behind an entire bank of thunderheads.  We were uniformly upbeat as we made our way in the growing blackness through the national forest.  Unlike the way most rains begin, that night the sky seemed to open upon us like a burst paper bag.

“Get our bearing,” I instructed Dothan.  As it was my idea, I was now the de facto leader.  As we were in a gully, getting our bearings required Dothan to climb a large evergreen.

“I don’t see it,” he hollered over the wind-swept rain squalls.  I scurried up, certain that he was either an idiot or blind.

“Do you see the light?”  They asked me.  I looked again.  Checked my map.  Checked my compass.  “It has to be there,” I yelled.

A voice floated up to me.  To me I thought it probably sounded a lot like the voice Moses heard from God as he was building the Ark.  (Just checking to see if you’re paying attention.)  “What if they turned off the light?”

I almost fell out of the tree like an apple testing the laws of gravity.  What if someone had turned off the light?  There was no ‘what if’ to consider.  That is exactly what happened.  Some inconsiderate homeowner had turned off their porch light and left us stranded.

Fast forward.  We were lost, real lost.  We didn’t finish last, but we did earn extra exercise the next day, penalized for being creative.  Who’da thunk it?

Short cuts.  When they work, you’re a headliner.  When they fail, chances are you’re also a headliner—writing the wrong kind of headlines.  I hate being redundant, but with EHR we may be dealing with the single largest expenditure in your organization.  It will cost twice as much to do it over as it will to do it right.  If you haven’t done this before—I won’t embarrass anyone by asking for a show of hands—every extra day you add to the planning process will come back to you several fold.  There may be short cuts you can take, but planning should not be one of them.  How much should we plan?  How long should it take?  Who should participate?  We will look at each of those questions in some detail.  For now, let’s answer those three questions with; more than you think, longer than you’ve planned for it to take, and different skills than you’re currently using.

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

My profiles: LinkedInTwitter
My blog: Healthcare IT Strategy My thoughts on “One EMR Vendor’s View of Meaningful Use”

How to Revive a Failed EHR Implementation

My latest post on  Here’s an idea I think merits consideration.

What do you think?

“How many days ago was Sunday?”

The photo comes from my Robert Redford look alike period.

Do you ever awaken wishing you were all you used to think you were before you figured out you weren’t?  Me either.  I’m someone who has these kind of days when it’s best to keep me away from shiny objects.

During college, I spent several summers volunteering for a group called Young Life at their camps throughout the US.  Silver Cliff was one of their camps in the mountains of Colorado.  Each week we’d take in a few hundred high school kids from throughout the US, and give them the opportunity to do things and challenge themselves in new ways; everything from riding horses to rappelling.

The prior summer I was the head wrangler at one of their camps—I had never ridden a horse prior to being placed in charge of the riding program.  This summer is was the person running the rappelling program.  Needless to say, I had never done that before either.

We received a day’s worth of instruction before we were turned loose on the kids.  One of the first things we had to learn was that the ropes and harness, if properly secured to the carabineers and figure eight, would actually keep you from falling to your death.  The first test was jumping from a platform way up in a tree while on belay.  After a few moments of white-knuckle panic, I stepped over the edge and was belayed safely to the ground.

From there, we scouted a place for the rappel, and found two suitable cliffs, each with about a hundred foot vertical drop.  Watching my first rappel must have reminded others of what it would have been like watching a chimp learn how to use tools for the first time.  After several tentative descents, I was able to make it safely to the bottom in a single jump.

Each day we’d run a few dozen kids through the course, ninety-nine percent of whom had never rappelled, or ever wanted to rappel.  To convince them that it was safe and that they could complete it, I would instruct them in the technique as I hung backwards over the chalk face of the limestone cliff.

Each day we’d have one or two kids who wanted nothing to do with my little course.  Occasionally, while on belay, one of them would freeze half way down the cliff, and I’d have to belay down and rescue them.

Once or twice I’d have an attractive female counselor on belay, her knowing that I was the only thing keeping her from being a Rorschach stain on the rocks below.  Scared, and looking for a boost of confidence, “She’d ask, how long have you been doing this?” I’d look at my watch and ask her how many days ago was Sunday.  I viewed it as an opportunity to have a little fun with her—sort of like turning to your friend in the checkout line in 7-eleven and saying loud enough for others to hear, “I thought we agreed we weren’t going to use our guns.” I also hoped maybe even having to go on a heroic rescue.

How long have you been doing this?  That’s seems like a fair question to ask of anyone in a clinical situation.  It’s more easily answered when you are in someone’s office and are facing multiple framed and matted attestations of their skills.  Seen any good EHR or HIT certificates on the walls of the people entrusted with the execution of the EHR endowment?  Me either.  I have a cardiologist and he has all sorts of paper hanging from his wall.  Helps to convince me he knows his stuff.  Now, if I were to pretend to be a cardiologist—I’ve been thinking of going to night school—I’d expect people would expect to see my bona fides.

Shouldn’t the same logic apply to spending millions of EHR dollars?  Imagine this discussion.

“What do you do?”

“I’m buying something for the hospital I’ve never bought.”


“The feds say we’ve got to have it.”

“Oh.  What’s it do?”

“Nobody really knows.”

“How long have you been doing this?”

“How many days ago was Sunday?”

“What’s it cost?”

“Somewhere between this much,” he stretches out his arms, “And this much,” stretching them further.

“Do the doctors want this?”

“Some do.  A lot don’t.”

“How will you know when you’re done if you got it right?”

“Beats me.”

“Sounds like fun,” she said, trying to fetter a laugh.

Sounds like fun to me too.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

Do you need to fire Ferguson?

It may be time to fire Ferguson.

I was listening to Imus the other day as he was interviewing the famous promoter, Jerry Weintraub.  The promoter relayed a story about one of his clients, John Denver.  Mr. Denver was constantly complaining about a number of things on one of his European tours, and he demanded the promoter come speak with him.  Here’s a replay of the conversation.

“Yes. Well, he was in Europe, and he was on tour. And everything was wrong. He hated everything. He hated the venues. He hated – the airplanes were no good. The sound systems were no good. Everything was no good. And he said to me, you know, I’m going to fire you; everything is wrong here. I said, yeah, I know, I know.

I sat down with him; I said, John, everything is going to be fine. He said, why? Why? I said, because I fired Ferguson. He said, why did you fire Ferguson? Why? What does firing him – going to do? I said, he’s been responsible for all the things that you’re troubled by: the hotels, the sound system, the venues, da, da, da, da. And he said, it’s going to be OK now? I said, yes, I’m putting other people in. Great.

And that evening, Denver and I went out to have something to eat. At dinner, I said to him, John, you know, I feel really terrible about firing Ferguson. He said, why? I said, because it’s not like you and it’s not like me. And John Denver said to me, I agree with you; it’s not like us. What can we do to help the guy? It’s really not like me. I got to help him. I said, I’ll put him in another area in the company. He’ll be fine. We’ll take good care of him. He said, that’s great, I feel so much better. Of course, there never was a Ferguson.”

Sometimes you need to shake things up a bit.  Do you need to fire Ferguson?

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

The definitive EHR Buying Guide

EHR Buying Guide—Vendor darts

So, here’s the thing with what a lot of EHR vendors seem to view as the lower end of the food chain, chum worthy customers—Hospitals, IPAs, group and individual practices.

Vendor darts.  I can’t tell you the number of providers with whom I’ve spoke who’ve had to navigate the chum-filled water of vendors trolling for dollars.  Unfortunately, when they come to your door, most of you are ill equipped and ill prepared to know whether you need what they’re selling.

It’s like playing EHR vendor darts—by the way—you’re practice is the dartboard.  Vendors fling their offering at you and hope they stick—the other way to play is to use the vendors as the darts, but you have to sharpen them or they’ll simply bounce off.

Just between you and me, or among us—if you’re a stickler about English—I’ve played vendor darts for years, and it’s always difficult for the dartboard to win.  (I am speaking parenthetically so they can’t hear us.)  We both know this is meant to be somewhat tongue-in-cheek.  The EHR vendors are professionals, and they have the utmost belief in their product, just as they will if they change firms and have to sell another product—this is the unspoken dirty linen of software.

There are a few hundred purported EHR solutions.  Each is a little different.  Which one is best for you?  Do they know which one?  If we are honest, the answer is, no, they don’t.  They do not know, they cannot know what features their competitors offer.

For those of you with any background in selecting software, any kind of software,I want you to do something for me.  Go to Google Search and enter “EHR RFP” and see what you find.  You won’t find anything helpful, anything that will help you select an application.  Big hint–if you cannot find something on Google, it does not exist.  That begs the question, what have providers been using to select an EHR vendor–rock, paper, scissors?

Vendors want you to stay focused on features.  Guess what?  Almost all of the leading products have just about the same features.  I want you to stay focused on business problems.  What business problems of your do their features solve?  It’s a fair question.  They should be able to answer it, and you should be able to answer it.

Rule number 1:  Any time a vendor tells you, “This is how we get our system to do that”, means their system doesn’t do it.  Those words signal a workaround, not a workflow.  It means they want your business to adapt to their way of manipulating how your business runs.  Have they ever run your practice; don’t think so.

Rule number 2: Vendors hope you don’t know about Rule 1.

What can you do?

  1. Work with someone who can spell out your requirements in detail.
  2. Work with someone who can navigate the chum field on your behalf.
  3. Assess some of the free EHR systems

Or, without meaning to be too gauche, contact me.

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

Why is EHR not the right answer?

The reason I chose to share this story is my belief that it is de rigueur among practitioners.  I have been spending some of my time working on behalf of a small clinic.  Four doctors, two offices, small lab, x-rays, some surgeries.

Great people, great mission.  Every physician spends several weeks each year doing unpaid missionary work in Africa and South America.  Their focus is caring, not dollars.  It is not my job to change their focus.  They do not turn away anyone who cannot pay.  Staff at the front desk help patients pay for their meds.  The four physicians routinely offer services and perform procedures for which they know they will not be paid.  I feel a real sense of pride helping them, and have slashed my rates to make sure they get the help they need without taking money unnecessarily from their coffers.  Their patients love them, and they add about a hundred new patients a month.

The business side of their practice could have been designed by Rube Goldberg.  As I interview the doctors, the nurses, the lab, and the front desk about the practice, I try to do so with a straight face, try not to betray the part of me that wants to say, “You’re kidding, right?”

They meet with about fourteen-hundred pharmaceutical reps each year.  I tried to pin down why they do it, but could not come up with an answer to support a business reason.  Since the pharma reps can no longer offer trinkets equivalent to those needed to purchase Manhattan, they give away lunch.  Enough lunches to ensure that everyone in the practice should weigh eight-hundred pounds.

They use the F-word a lot—faxes.  Two fax machines running often enough that without proper cooling they would melt through the floor.  The average fax is handled eight times before it is placed in the patient’s chart.

There is no email, no web site.  There is no triage—docs and nurses do not screen patient phone calls to determine who needs to be seen.  Seventy-five patients a day, two and a half people are full time on billing.  Three people man—actually, it should be “woman”, the front desk.  (Is that an intransitive verb, or simply poor writing on my part?)  The staff wants more staff.

I have been hired to help them with the selection and implementation of their EHR.  I can solve the EHR problem in five minutes, but I won’t.  Having an EHR will solve none of their problems, at least not until they turn what they do into a business.

Realigning their business processes will do more for their mission than any EHR.  Processes are inefficient and ineffective.  I cannot figure out how they collect money or pay bills.

I am willing to bet they are not alone in having these issues.  I’d bet that these problems can be extrapolated to hospitals.  Is Practice Management more important to physicians than EHR?  My guess is that the right answer is yes.

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

EHR, where’s my hammer?

Those of you who’ve visited previously may have caught on to the fact that my wife likes to keep me away from bright shiny objects such as tools.  Let me tell you about my first house, a two-story stucco building in Denver, built in 1902.  My favorite part of the home was the brick wall.  That is had a brick wall was not apparent when I purchased it.

I came home from work to find that my dog had eaten through the lath and plaster in the living room and there was the brick.  I had to decide what to do.  I knew nothing about lathing—I know that’s not really a word—or plastering.  What to do.  My only tool was a hammer, so I began to hammer.  For those who haven’t done this, hundred year old plaster being pounded with a hammer makes a lot of dust.  This process proved to be very slow.

What did I do?  I bought a bigger hammer—such a guy approach to a problem, isn’t it?  It took three hammers to get down to just bare brick.  What would you have done?  When your only tool is a hammer every problem looks like a nail.

As you go through the EHR planning process in your war room—you do have a war room, don’t you?  (Try Sam’s Club, after all, they sell EHRs.)  Get out the really big piece of paper, the one with your EHR design—you do have a really big piece of paper, don’t you?  (Back to Sam’s.)

Next to the box on the paper labeled “Shiny New EHR” should be lots of empty space so you can draw in all of the other systems with which your EHR will have to interface.  One of the readers of this blog wrote recently that his EHR had more than 400 interfaces.

EHR, if done correctly, will do much for patients, doctors, and administrators.  It’s not a panacea.  It won’t reach its potential unless you also integrate it with those systems that unlock its potential.  Improving your efficiency and effectiveness takes more than merely an EHR system.

When your only tool is a hammer, you’d better hope every problem is a nail.  What other tools are you using?  Please share your ideas about what works well.

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

EHR: What bugs you about it?

This is the time of year in the east when cinerescent caterpillar nests hang thickly from the trees, peppered tufts of cotton candy.  During these long, flavorless August days, the sky is a similar achromatic color.  My nine-year-old is concerned because I told her we are having caterpillar soup for dinner tonight—watch out for the crunchy bits.  Once again, it seems I’ve gotten off message.

I wonder how much of the difficulty surrounding EHR has to do with getting off message, much like we seem to have done with the reform discussion.  What difficulties?  Got time?  You can name more of them than can I.

What is off message?  It’s that the day-to-day tactics of implementing EHR office by office, and hospital by hospital have overshadowed the strategy, have displaced the business driver behind the mandate.  The focus became internal, not national.  Bits and bytes have overshadowed charts.

I doubt few, if any, can articulate a believable explanation of how a few years from now your medical records will accurately and expeditiously be delivered from where you live to the lone clinic on Main Street, Small Town, USA, to the nurse practitioner who at midnight is giving you an EKG.

It’s that fact, that we are not able to define how we get from A to B, let alone do so with multitudes of A’s and B’s, that to me suggests we are building something of which we have little comfort will do what we set out for it do.

Clearly, there are hundreds if not thousands of very talented and dedicated professionals focused on finding a solution.  However, it seems their efforts remain handcuffed by hundreds of competing products, no well-defined overriding set of requirements that would enable anyone to say with certainty, “Yes, that is it.  That captures what we need to do.  When we have done that, we are done.”

Until that time, I think we all need to be concerned about the crunchy bits.

saintPaul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

July is “take your EHR strategy to lunch month”

Several have written suggesting I toss my hat into the ring to serve as the EHR Strategy wonk or czar.  I was in the process of thinking it through when I was awakened from my fuegue state by a loud noise–my ego crashing to the floor.

Some have suggested that a camel is a horse designed by a committee.  Their point in saying that has something to do with how committees function less well than individuals–the problem with “group thinking.”  Personally, I think the camel design seems rather functional.

Some have asked, what is it about the EHR universe that has you dehorting the EHR process as though you are some sort of savant–nobody really asked that, but I wanted a segue and that’s all I came up with.

It’s the committees.  I feel a little like Quasimodo repining about the bells.  Raise your hand if you are on an EHR committee.  See?  Now, if you think that not only has the committee not accomplished much, but believe that it may never accomplish much, lower your hand.  Now look around.  Not many hands still up.

Please take a look at this for a moment.  Don’t try to understand it–it will only make your teeth hurt.

2011 requirements

  • For hospitals, 10% of all orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) directly entered by an authorizing physician must be made through a computerized physician order entry process. Individual physicians still must use CPOE for all orders, even if electronic interfaces with receiving entities are not available. The initial draft did not specify the required percentage for hospitals and did not address the electronic interface issue.
  • Physicians must be able to check insurance eligibility electronically from public and private payers, when possible, and submit claims electronically. This was not in the initial draft.
  • Patients must receive timely electronic access to their health information, including lab results, medication and problem lists, and allergies. The initial draft did not include the word “timely.”
  • Physicians must implement one clinical decision rule relevant to specialty or high clinical priority. This was not in the initial draft.
  • Physicians must record patient smoking status and advance directives. This was not in the initial draft.
  • Physicians must report ambulatory quality measures to CMS. This was not in the initial draft.
  • Physicians must maintain an up-to-date list of current and active diagnoses based on ICD-9 or SNOMED. The initial draft did not specify use of the two classification sets.

2013 requirements

  • Specialists must report to relevant external disease or device registries that are approved by CMS. This was not in the initial draft.
  • Hospitals must conduct closed-loop medication management, including computer-assisted administration. This was not in the initial draft.
  • All patients must have access to a personal health record populated in real time with health data. This was moved up from 2015 in the initial draft.

Additional provisions

  • Patients’ access to EHRs may be provided via a number of secure electronic methods, such as personal health records, patient portals, CDs or USB drives.
  • CMS will determine how submitting electronic data to immunization registries applies to Medicare and Medicaid meaningful-use requirements.
  • CMS may withhold federal stimulus payments from any entity that has a confirmed privacy or security violation of the Health Insurance Portability and Accountability Act, but it may reinstate payments once the breach has been resolved.

Source: Health IT Policy Committee

See?  Take a few minutes and work this into your EHR task time-line for processes, work flows, change management, training.  Need more time?  I’d need more time than I have, and when I finished I guarantee I couldn’t explain it to anyone.  This is what happens when people get into a room, have a charter, and try to do something helpful.  I am sure they are all nice people.  But be honest, does this make your day, or does it make you want to punish your neighbor’s cat–you may have to buy them a cat if they don’t already have one.

What to do?  Here’s my take on it.  Plan.  Evaluate the plan.  Test the plan.  Know before you start that the plan can handle anything any committee tosses your way.  Let people who know how to run large projects into the room.  Seek their counsel, depend on them for their leadership.  If the plan is solid, the result has a better chnace of surviving the next committee meeting

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