Revising your work flows?

revised work flowAs a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

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

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EHR-the 40 chicken crocodile

Got a couple hundred million burning a hole in your pocket?  Why not buy an EHR?  Indeed.

Riddle me this Batman, “What is a 40 chicken crocodile?”

It is the number of chickens you have to feed it each day to keep it from eating you. What is the crocodile at your hospital?  Is it your EHR?

Let me recount to you a true story about the details of one of the EHR “success” stories.  A major hospital who selected their EHR from among one of what I like to call the oligopoly EHR Flavor of the Month Club.  You know the suspects.

Permit me to throw a wrench to those clairvoyants who think they know where this is going before I’ve even written it.  Admittedly, I have a tendency to throw metaphorical tomatoes in one direction—that of the vendors.  That’s because, they are often easy targets.  Slow down Pepito.

This hospital, and from what I was told, the vendor, did it right.  I am not sure I would have differed from the approach of either.  The hospital spent a few years in its vendor selection process, and they were very thorough.  They spent two years building their process maps, ensuring the vendor implemented the EHR to meet their needs, not the other way around.  Operations led the nine-figure project.

They implemented many of the support functions and a few of the specialty functions.  Here come the chickens.  After implementation, cash flow dropped by 80 percent for several months due to significant issues they encountered cleaning up the revenue side.  Doctors were instructed to cut their hours by fifty percent to allow them to learn to use the system.  Hours are still down by twenty percent, well more than a year later.  Users use about one-third of the functionality, even after a rigorous training program.

The hospital held off doing most of the clinical implementations for two years.

I asked for some recommendations.  What would you have done differently?  Here’s what I learned.  If you have a research organization you need to spend extra special attention to their workflows.  Managing post-go-live was a big issue to begin to offset productivity losses. Without a continuous process improvement program the EHR would not have been accepted. Do not pick a go-live date at the outset of the project as it causes the organization to be paralyzed simply to hit the date.  Testing was compromised to meet the go-live date. The post go-live issues are still being fought.  Do not let the design or build teams skimp on either reporting or testing, they are still playing catch-up.

So, after doing a pretty bang up job, at least from where I sit, there are still a lot of chickens being fed to the crocodile.  Wonder how many chickens it would have taken had the users not been as involved as they were.  How many had the users not spent two years pre-build defining processes?  A lot.  Now comes the rest of the clinical effort.  See you at the poultry counter.

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

The User’s Role in EHR–a PowerPoint presentation

This link will take you to a slideshare,net presentation that defines how healthcare providers can take control of the EHR project.  I welcome your comments.

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

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

Should you listen to the voices in your head?

Well, for starters, if you don’t nobody else will.

Just because I’m paranoid, doesn’t mean the voices in my head aren’t real. What voices?  They don’t like it when I speak of them, so I am going to speak in parentheses so they do not hear me.)

Riding the in the car yesterday with my son, the radio was playing Barber’s adagio, a mournful and eerily melancholy piece. It has long been one of my favorites.  I tried to get my son to turn off his PSP long enough for him to try to develop an appreciation for it.

He asked me to tune the radio to what he calls ‘his’ station while I kept extolling the specific virtues of the adagio, of Barber, and of classical music in general. I intended to win him over to my way of thinking.

The phrases I used to bolster my opinion kept coming to me, although I knew not from where.  I soon reached the point where I knew that I was no longer speaking to him, but role playing the very same discussion I had had with my father when I was about the same age as my son. Déjà vu. I have become my father’s son. The voice in my head was my father’s and I was not even charging my father rent for the space.

Do you hear the voices? No, not those voices. The ones you hear at work when you realize that the person speaking to you is your other self. The same voice you hear when you go out after work with your friends and begin to talk shop. By the third glass of wine the conversation has shifted from swapping stories about the craziest patient to wondering aloud when the company is ever going to learn how to fix their business. By glass five, you’re fixing it for them, diagramming solutions on cocktail napkins.

A word of encouragement. Listen to the voices. I bet you’ve come up with some great ideas. They won’t do anyone any good locked up in your head. Let them out. Show someone who can do something about it what you wrote on the napkins.

What are the success factors for EHR?

I just arrived in-country—I was in Wisconsin for two weeks.  I’ve been to forty-seven states, and Wisconsin has to be one of the friendliest.

Anyway, let us begin.  Not long after graduating with an MBA from Vanderbilt, I returned to Vandy to interview job candidates.  With me, was my adult supervisor, the VP of human resources—a stunning older woman; about thirty-five.  At dinner, she invited me to select the wine.  Not wanting to appear the fool, and trying to control my fawning, I pretended to study carefully the wine list.  Not having a clue, I based my selection entirely on price.  I had little or no knowledge of the subject; nonetheless, I placed the order with all the cock-sureness of a third-grader reciting the alphabet.

A few moments later Wine-man returned with a bottle, angled it towards me, and stood as rigid as a lawn statue.  After a few seconds my adult paused and motioned my attention towards Wine-man.  I remained nonplussed.  “You are supposed to tell him that the bottle he is holding is the one you ordered.”

“He knows it is what I ordered, that is why he brought it.”  I thought they were toying with me.

A few seconds later there was a slight popping sound and then Wine-man placed the cork before me on my napkin in a manner similar to how Faberge must have delivered his fabled egg to Tsar Alexander III for his wife Empress Fedorovna.  They were both staring at me, not the Tsar and the Empress—Wine-man and my adult.  “You are supposed to smell the cork.”  And so I did.

“Now what?”

“If it smells bad, it means the wine may be bad.”

To which I replied, “This is the Opryland Hotel—have you seen the wine prices?  They don’t sell bad wine.”  She nudged me with her elbow.  I could tell I was wowing her.  I smelled the cork.  “It smells like a cork,” I whispered to Wine-man.  He smiled and poured a half inch of wine in my glass.  I thought he was still pulling my lariat.

I looked bemusedly at the mostly empty glass, held it out to him, and asked him if I could have some more—I was thirsty.  Rather than embarrass me further, with a slight nod of her head my adult instructed the Wine-man that my sommelier class was over—any further proof of my inadequacies would be of limited marginal value.  Any chance that we would have gone dancing later that evening was about as flat as the wine.  I should have ordered a beer.  I was good at beer.

For those who are still reading, if you are wondering if I am actually going to make a point, here it comes.  I’m not fond of segues, so don’t blink.

Sometimes, a little guidance is helpful—even if it has to come in the form of being led around like camel with a ring through its nose.  One of my on-line friends, a nurse who teaches nursing—seems like a good fit–asked me what are the success factors for EHR.

Often, what is important in a leader is having the knowledge and temerity to ask the right question.  In healthcare it appears that the number of executives with answers may exceed the number asking questions.  Value is often measured by scarcity.   Good questions, especially around EHR and Meaningful Use, seem to be in short supply.

Here’s my take on some of the critical success factors:

  • Adult supervision—this is not defined by the age on your driver’s license
  • Invest time to plan your EHR plan; 6-9 months for a fair sized hospital
  • Actual written requirements (an RFP) that comes from your business strategy
  • A written healthcare information technology plan
  • Invest more than half of your time and effort in work flow alignment, change management, and training.
  • Should your plan seek to meet Meaningful Use
    • By when
    • How
    • What drives your strategy—Washington or your business model

Pretty simple things.  The right things usually are—like knowing what to do with the wine cork.

EHR: Is your scope wrong? I bet it is.

The hand-written note, scrawled in the best penmanship of my nine-year-old daughter, lay next to the plate of sugar cookies and the warm glass of milk.  It was eleven PM.  Three kids lay in their sleeping bags, asleep on the floor of the play room—cameras ready to capture images of the annual intruder.

Illuminated by the glimmering lights from the tree, I scanned her note.  Two pages.  Itemized.  Fifty-three lines, fifty-three items.  Requests.  The letter begins, “Dear Santa.  I wrote this list today.  I know you already got my letter.  These are other things you could give me.  Please leave them under the tree with the rest of my presents.”

There are a number of ways to view her letter.  It certainly is cute—it’s probably cuter if you’re not her parents.  You know what occurred to me at 11 PM as I stood there in my slippers eating the cookies and drinking the warm milk to reinforce the message to my children that Santa exists?  Two words.  Scope Change.  Plain and simple.

Weeks of thoughtful planning, buying, and wrapping possibly shattered by the scratchings of a number 2 pencil.

Make no mistake; this will happen to you on your EHR project.  Scope change.  Where will it come from?  Users, vendors, the CFO, reform.  Most projects fear change.  Change is feared because the project team never quite got their arms around the original scope.  Most change means more dollars and more time.

Scope change can be healthy.  Why?  I bet most EHR projects are under-scoped.  Did you read that correctly?  Yes.  I bet if an independent party assessed your scope document and work-plan you will find you are under scope in these three areas:

  • Change management
  • Work flow improvement
  • Training

If that’s the case, you will have spent tens of millions of dollars building something slightly more functional than a rather intricate Xerox machine.

EHR meeting etiquette and survival guide






How many times have you been involved in one of those EHR committee meetings whose purported purpose was to elicit ideas?  I find it to be a helpful barometer to scout the room and see if the person who offered an idea at last month’s meeting was invited to this month’s meeting.   To survive across months of meetings requires a lemmingesque ability to walk in silence to the edge of the cliff.

Don’t be fooled into offering an idea simply because the leader is doing that tricky thing about using silence to see who will get so uncomfortable that they just need to hear a voice–their own.  Mistakenly, you believe that someone is actually interested in what you have to say, and you toss your idea into the black hole that used to be your career. Your idea is met with silence, the kind of silence you hear on a warm summer night. You swear you can discern the chirping of individual crickets outside.

Those voices you’ll been talking about in counseling are trying to warn you.  But to no avail, out it comes; “How come we’re not doing those work flow things they talked about?”  “Why did Our Lady of Perpetual EHR Hospital use and RFP to select their EHR vendor?”  “Why is radiology bulding their own EHR?”  “How come nobody is worried about whether this system will allow the referral docs to connect?”

You notice that your brother-in-law, the CMIO, has moved his chair away from yours.  Your best friend’s eyes are locked on his Blackberry.  It’s only then you learn that you and your colleagues aren’t petting the same dog. I think EHR implementations are a lot like that. There’s a lot of talk about doing something new, but more often than not it’s just talk.


Stilleto Change Management







I just returned from the Prada show in Milan. Not really—that was the opening line from a piece on NPR. Apparently this year’s runaway hit on the runways has to do with high heels, with the emphasis on the notion of high.

The following comes from the UK Telegraph: The girls looked like rabbits trapped in the headlights; their faces taut and unsmiling, their eyes wide with fear and apprehension. Were they about to undertake a parachute jump? Abseil down a 1,000ft mountain? None of the above. All they were doing was trying to negotiate the catwalk at Prada during this week’s Milan fashion shows in shoes that were virtually impossible to walk in. At least two models tripped and fell on to the concrete floor; others wobbled and stumbled, teetering and tottering, clearly in agony, and all the while their minds were fixated on just one thing: reaching the sanctuary and safety of the backstage area without suffering a similar fate.

According to the NPR reporter, the heels are so high that regular people—women people that is—can’t seem to walk in them without falling. This problem has led to the creation of an entirely new micro-industry. In L.A. and New York, there are classes to teach ladies how to walk in very high heels without hurting themselves. These classes are being offered through dance schools that couldn’t fill their dance classes—they are now booked solid.

Tell me this isn’t the same as trying to walk and chew gum at the same time. Multitasking. Now before I make fun of some thirty year-old that has to relearn how to walk, let us turn our attention back to those dancing—cum—walking schools. From a consultant’s perspective what makes this story interesting is that those businesses saw a need and re-engineered a part of their operation to meet that need, sort of like we’ve been discussing regarding the impact EHR and reform can have on your organization.  With the implementation of EHR, many things will change.  If they don’t require change, you probably wasted your money on the EHR.  What’s important is having a plan to define the change and manage it.  Rework work flows, remove duplicated processes and departments.

Now I’m going to go saw the heels off my wife’s shoes before she hurts herself.


Work Flows–learn to color outside the lines


Somewhere out there is the person or persons who invented Chuck e Cheese. I am convinced that whoever deserves the credit either does not have children, or if they do, does not take their children to Chuck e Cheese under any circumstances. If you’ve never been, it’s one of those places whose true cacophony must be experienced first-hand. The FDA should conduct clinical trials of blood pressure medicines there. The formula is simple; machines that make noise plus kids that make noise equals happy kids. Some parents are immune to the noise. I’m not some parents–never have been, don’t see it happening any time soon. I could feel the pressure build, the parents around me were coping the best they could. One father whose eyes looked like those in Edvard Munch’s painting “The Scream” was popping Xanax like they were jellybeans.

I collected a group of parents and we sequestered ourselves behind the skeet-ball. “We’ve got to come up with something to ensure we never have to do this again,” I whispered, trying to rally my charges.

“I can’t do this anymore,” replied a frail-looking man who had developed a nervous tick.

I paused and pondered as an idea flittered past my id. Then I started a smile which soon covered my face.

“What?” asked Tick man.

“Yes, tell us,” implored The Scream.

It was a coloring outside the lines idea if there ever was one. “WebEx,” I barked as the idea began to take shape. “We do virtual birthday parties on WebEx. We each login our children from the comfort of our home. No screaming kids, no cold pizza, no spilled soda. It’s perfect. While they’re doing that, we can be in another room watching football.”

The idea had legs right up until the point where my wife overheard it. “You old Grinch. Get back over here with your son.” I caved, but I’m holding the idea in reserve.

Thinking outside the box. In creating the vision for re-engineering your work flows, why start there? That’s where everyone starts. Remember, if everyone’s thinking outside the box, all that means is that the box has moved and everyone is back in it. Why not create a vision that includes something like re-engineering all non-clinical patient-facing activities? A stretch goal is not trying to reduce billing calling by fifty percent. That’s what world class providers are trying to do. Other stretch goals might be asking questions like;

1. What would have to happen to the practice to be able eliminate eighty percent of all patient complaints?
2. What would it take to move half of all patient contacts to the web?
3. What would happen to first patient satisfaction if you set a goal to use social media to explain how to resolve claims problems?

So, where are we? We need a project champion, who has executive sponsorship, and who is willing to create a vision that has some legs.

Oh, I forgot to mention that after we left Chuck e Cheese we had all the seven year-olds over to our house for a sleep over.  I should have stayed at Chuck e Cheese; it was quieter.