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

Failed EHRs: Maybe it’s the jeans

There I was listening to NPR while driving home from the airport.  Their lead story was about Levis’ announcement of a new line of custom-fit jeans for women.  They developed the line after studying the shapes of more than 60,000 women—I guess that is good work if you can get it.  Levis somehow determined that 80 percent of all the women on the planet fall into three distinct categories, Curve IDs.  (Does that mean the other twenty percent fall into roughly 3,752,841 body types?)

Why did Levis go through all this effort?  Apparently 87 percent of women say they can’t find a pair of jeans that fits them.  Fifty-four percent stated they try on at least ten pairs of jeans before deciding on a pair.  I concluded from a few of the things I read on Google that for those whom believe the jeans don’t fit—must be a lot of bad jeans out there.

There are a lot of failed EHR implementations out there.  How do I know that to be true?  I studied the shapes of more than 60,000 failed EHR implementations and, guess what?  They fall into three failure categories—EHR Failure IDs—lack of due planning, lack of process change, and lack of user involvement.  I guess it’s difficult to get an EHR to fit…Kind of like finding a good pair of jeans.

Here’s my take on the matter.  Chances are that whatever EHR does not seem to fit in Provider A is fitting just fine at Provider B.  How could that be?  Same system.  Same code.  The functionality of the system has not changed in the time since it was selected.  Maybe the reason the EHR does not fit is not the fault of the EHR.

That said, there are those of you who think I may tie this discussion back to the discussion of the jeans, and write something like, “Maybe the reason the jeans do not fit is not the fault of the jeans.”  I may be dumb, but I am not that dumb.
Kind Regards,


Paul M. Roemer
Managing Partner, Healthcare IT Strategy

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

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

The Services We Offer

What we have here is a failure to communicate, and unfortunately the failure is mine.

It has been a week of learning.  According to one of the thought leaders in healthcare, whom I’ve known for more than a year, he does not understand what services my firm offers hospitals, and he thinks others may have the same problem.

He suggested it would be helpful to spell it out, service by service.  So here goes.

Program Management:

We work with hospital CIOs and COOs as their advocate by serving as the program management officer (PMO).  We define functional requirements, select software, and manage IT applications vendors for enterprise applications like EHR, CRM, and ERP.

Operational Efficiency:

We work with the hospital C-suite to identify, define, and implement a unique set of business processes and business rules, eliminating duplicated processes and those which do not add value.  The output is a single set of best practices processes and rules.

Change Management:

Enterprise applications will alter business processes and impact most employees and patients.  Without a rigorous change management effort, the impact of the application on the hospital’s processes and people will be a disaster.  We figure out what must change, how it will change, and how to pull it off.

Patient Relationship Management (PEM):

This is the hospital equivalent of Customer Relationship Management (CRM).  On a PEM project we define the requirements, select an application vendor, define the processes, and manage the project to completion.

Please let me know if you need help with any of these.

A guest post–An EMR that increases productivity

The following is a guest blog by James T. Loynes, MD.  During a recent call he told me about an EMR he wrote for his oncology practice.  My initial thought was, “Just what we need, another EMR.”  The more I listened, the more I thought he had something different, something that actually was built towards an eye for best practices.  I asked him if he would tell you about it.  The rest of this is his.

The Path to Excellence Is Under Construction

James T. Loynes, MD

No really, I am not crazy.  I just want to do things better.  That’s the reason I built my own EMR.  I worked with an excellent group of programmers to design my Hematology-Oncology EMR piece by piece over a period of three years.   I fixed every design flaw and mistake.  Problem by problem I made it right.

It wasn’t easy and it wasn’t quick.  I examined how I care for patients.  I evaluated how paper and information flowed through my office.  I met with nurses, secretaries and transcriptionists to determine how we could do things better.  I knew that technology could be a powerful tool to improve patient care.

Even as a medical student, I never understood why it was so hard to find patient information.  Charts could be lost or misplaced.  Medication lists were always a moving target.   Why couldn’t we use technology to make things easier and more efficient?  I was annoyed that I had to dictate the exact same information visit after visit.  I was consistently slowed down because I had to find and repeat documentation.

I listened to stories from patients about other physicians who spent entire visits looking at the computer screen because that is what their EMR demanded.  I saw EMR generated notes that had so much information that it was difficult to read.  I made it a point to avoid these pitfalls.

I needed my EMR to make me better, smarter, and faster.   Since there was not an oncology EMR available that filled my needs, I built my own.  I started by designing a web based program that helped me with my chemo orders.  I designed it to fit my (physician) needs.  I wanted to be more efficient.  I wanted to take better care of patients.  I wanted to be able to find information when I need it.

I like paper!  I know this is EMR blasphemy, so don’t tell anyone.  I can write on it, put it in my pocket, or give it to someone.  It is easy to read and anyone can use it!  You know what else I can do with paper?  I can throw it away or recycle it.  While I like paper, I don’t like to file or find it.  As we all know, maintaining a paper chart demands a huge amount of work.  A tremendous amount of time is spent finding, carrying, copying, thinning, and building a paper chart.  I decided that I need paper, but I wanted my EMR to get rid of the paper chart by electronically putting paper where I can find it on demand.

My EMR is web based.  I can access it with any computer that has internet access.  The system can support one physician or fifty. I have hundreds of templates that I can easily edit.  I have order templates, note templates, chemo templates, and nursing templates.  The system automatically fills in designated portions of the physician notes.  The EMR remembers information from previous notes and places in a manner that allows me to dictate new information only.  Dictation time and expenses are dramatically reduced.  Treatment calendars accurately track chemotherapy dates and cycles.  The nurses can write phone notes, enter vitals, and document core nursing measures.  They can perform medication reconciliation and take verbal orders.   I can easily monitor my billing codes and keep track of information needed for the ASCO Quality Oncology Practice Initiative.  I can build treatment plans and treatment summaries.  The system monitors chart access.  Preliminary notes or chemotherapy orders prep the EMR for improved productivity.   Patient lists speed up chart access.  Medications lists and visit summaries can be printed on demand.

This EMR could be easily altered to accommodate different practice specialties.  What would happen if you had 30 physicians in the same community using this web based EMR?  Providers at a small practice have access to the same technology as the largest practice.  Instead of 30 different methods of documentation, each provider could use the same system.  There would be nothing to download and very little equipment would be needed.   Communication would improve exponentially.  The whole community would save on medical costs because there would be less duplication of efforts.  The work of others could be viewed by all.  In the end, everyone benefits, and patients receive better patient care through the use of technology.  Alright, maybe I am a little crazy, but sometimes that’s what it takes.

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: there’s a difference between finished and done


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

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

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

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

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


EHR: Impact on DR Patient Relationship

feastI’m a fan of foreign films, but since I don’t speak the language for me to really enjoy the movie, the visual story must be really compelling.  I also love to cook, not from recipes, but creatively, making it up as I go along.  Fortunately for purposes of this blog, there is a film which does both—Babette’s Feast.

The Danish film is set in France in the early eighteen hundreds.  The story centers around a group of pious sisters who receive a visitor who offers to spend her lottery winnings by preparing a feast for them.  The visitor, Babette, happens to be a very skilled chef.  There are those who may think the movie’s plot has more to do with the interplay among the participants.  However, as I am not a professional movie critic, we can skip the interplay and fast forward to the parts I find most relevant, the feast.

(This paragraph comes from Wikipedia.)  The sisters agree to accept Babette’s meal, and her offer to pay for the creation of a “real French dinner”. She leaves the island for a few days in order to return to Paris, as she must personally arrange for supplies to be sent to Jutland. The ingredients are plentiful, sumptuous and exotic, and their arrival causes much discussion amongst the clan. As the various never-before-seen ingredients arrive, and preparations commence, the sisters begin to worry that the meal will be, at best, a great sin of sensual luxury, and at worst some form of devilry or witchcraft. In a hasty conference, the sisters and the congregation agree to eat the meal, but to forego any pleasure in it, and to make no mention of the food during the entire dinner.  The last and most relevant part of the film is the preparation and the serving of an extraordinary banquet of royal dimensions, lavishly deployed in the unpainted austerity of the sisters’ rustic home.

The denouement—I thought it appropriate to use a French word—is whether or not the piety of the guests will prevent them from participating in the feast. It wouldn’t have made for much of a movie if the guests never came and the food sat there getting cold, but what if?  What if there was all of this preparation and no guests?  What if she prepared the feast, and in her haste forgot all about the guests?  Indeed.

Has anyone felt that something is missing in the discussion on EHR?  There’s plenty of talk of Washington and payors.  ARRA and money.  Stimulus and penalties.  Where are the guests?  Are we all responsible for not inviting the EHR dialog to include the patients?  I know it’s there, tucked away somewhere.

We’ve discussed on several occasions the notion that EHR should not be about the EHR.  It should be about the users and the patients.  Nevertheless, how is it being viewed by those groups?  Is it seen as a success?

Let’s make it a little more personal—my recent trip to my cardiologist at a superb teaching hospital in Philadelphia, Pennsylvania.  I usually get about an hour with the doctor—face time—clinical, examination.  Important time to a heart patient, eye contact that communicates you are doing all the right things, your test scores are all off the charts in the right direction, and you are healthier today than most people twenty years younger than you who haven’t had a heart attack.

That’s the real reason I go for the annual checkup, not to find out what I should be doing—I know I’m doing those things, not to find out if I am sick because I know I’m not.  I am there to reap the comfort that comes from having this specific person tell me things that help me believe that if I continue to play an active part in my recovery I will be there to raise my children.

During my last visit, we had about ten to fifteen minutes of eye contact, and the rest of the hour was spent with me watching him enter data into the EHR system.  It wouldn’t have been his choice, and it wasn’t mine.  Other than the first ten minutes, my entire checkup could have been done on WebEx.

I wonder if they offer an EHR?

 Paul Roemer Business Card

Healthcare–0.2 to 2.0, mind the GAP

dog Alex van Klaveren raised a question in his blog, Medicexchange about a point we raised here stating that Healthcare is moving from version 0.2 to 2.0.

My thoughts on this center around differentiating between the business of healthcare and healthcare as a business. That they may not be easily separable makes it difficult. There are many factors which if viewed from the perspective of an MBA student that suggest the as a business (processes, management, use of technology to run the business) it is found lagging when compared to for example to banking and manufacturing. Healthcare is being pushed to catch up quickly, and has little guidance in how to get from A to B, and doesn’t understand how to define the Gap.

We’ve also stated that it’s not about EHR.  So then, what is it about–sorry for the preposition?  It’s about the Gap.  It’s about knowing where you are, defining where you want to be, and being able to articulate a strategy which will get you there.  It’s about change management, and work flow improvement.

My best – Paul