Author: Chandresh Shah

By Chandresh Shah

I was speaking with an experienced executive coach Uri Galimidi yesterday and he pointed me to one of his blog articles. As I read the article HOW GOOGLE CREATES HIGH-PERFORMING TEAMS, I realized how relevant it was in businesses of all sizes including medical practices: solo as well as large groups.

When we go to conferences and pick up new ideas to implement, we want to implement them in our practices. We feel positive they would work, yet sometimes we are confronted with failure. We change technology such as EHR systems and practice management systems. After going through an extensive evaluation, you come to the conclusion that what you choose is perfect for your practice. Yet many practices quickly realize that it did not work out.

I’m sure everyone has either gone through this themselves, or have heard stories of colleagues who have gone through this. I have personally encountered this so often that it is not even funny.

As I read the article I realized the real reason why things do not work out. The article talks about high-performing teams, which lead to successful project implementation. It has nothing to do with the IQ of people, their personality types, education, social backgrounds and so on. The article talks about various factors but I want to focus on the first one.

Psychological safety

This is been found to be the most important prerequisite for success in projects and personnel performance. It is really about ‘creating an environment in which all team members know that they can express their thoughts and ideas, and that they will all be heard – irrespective of their standing in the team’s dynamics. They know that they will not be “shushed down” or belittled for expressing even the most off-the-wall idea. They know that it is safe for any member of the team to talk about the “Elephant In The Room” without fear of retribution.’

Let us take the example of selecting and implementing EHR systems.

As the author talks in the initial part of the article about a crucial mission-critical project at Google, he talked about meeting with the employees. It was a detailed meeting asking employees about their opinions whether they are ready to go live or not. In addition, they were asked to write down top 3 risks or issues that may negatively affect the successful go live. Everybody said yes, yet there was one person who was scared and went along by saying yes but decided to speak to him in private about his assessment due to fear of his ideas being shut down publicly. As it turns out, the risk factor that this person identified was crucial to the success of the project.

Identifying and creating an environment of psychological safety along with trust and dependability are so important that I cannot stress that enough. If these parameters exist, in the environment of genuine trust and openness, the team will not only be able to identify risks but more importantly come up with solutions to overcome them in order to make any project successful.

Finally, as the article says, ‘although these concepts may sound trivial, they do require a conscious awareness and an investment in time and energy on the part of the team leader to create an environment in which her/his team will perform at the highest level possible. Turning these concepts from common sense to common practice will produce handsome dividends.’

Seth Godin’s blog below got me thinking. This is how we should evaluate software and technology products.

A simple dialog can turn opinions into plans (or perhaps, into less tightly held opinions).

We ask, “and then what happens?”

Flesh it out. Tell us step by step. The more detail the better.

No miracles allowed. And it helps if each step is a step that’s worked before, somewhere and sometime else. The other question that helps with this is, “has that step ever worked before?”

We don’t have a shortage of loud and strongly held points of view about business, culture, or technology. But it may be that finding the time to draw a map helps us get to where we want to go (or to realize that we need a new map). 

What does all this have to do with Product/Software Evaluation?

When doctors buy EMR software, majority of them make the mistake of doing an improper evaluation and testing before buying. This leads to dissatisfaction and practice inefficiencies. Medical clinics have a lot of moving parts and workflows. Doctors will evaluate from the clinical perspective. Office managers and billing staff evaluate the systems from their own workflow point of view.

Where it gets complicated is that they focus on inefficiencies and dissatisfaction with their previous software. They assume that other parts of the system work fine. The evaluation needs to happen as if you are buying a system for the first time.

Every step of the process must be evaluated independently.

DO YOUR HOMEWORK.

This requires a lot of homework. Start by documenting every step of the process. This is more difficult than it sounds, because you have been doing things for a long time and you take things for granted. You don’t do not feel the necessity to document simple steps. Once all the steps and workflow have been documented, this is where you need to ask the vendor, ‘then what happens?’ Keep on asking this question until you know the exact steps that you have to take in that software to do your job – everyone’s job.

There is another side benefit of doing this. It will prevent future finger-pointing. In majority of the cases many unspoken things lead to discontent. How many times have I heard, “I thought you said…”, Or, … “You never told me this…”

Do yourself a favor, and keep on asking “and then what happens?”. Spend as much time as necessary with the vendor evaluating the product.

Seth Godin wrote very well about Hope and Reality in our lives. “Sometimes, we don’t sell what we’ve got, we sell what could be.”

He gives the example of Bruce Springsteen’s autobiography. just the proposal can sell for $10 million, not the finished book. Why? It is what can be.

That’s how the Stock Market works.

That is how EHR companies sell. Hope. That is what Doctors buy – Hope.

Hope is not necessarily a bad thing if it is combined with due diligence and trust. The problem is not many providers and medical practices have experience in conducting proper due diligence on EHR systems. I have written about this in the past. Prepare instead of hoping.

The only way to get the maximum out of EHR demonstrations is preparation. I have seen too many demonstrations where they are all over the place. You must know what you want. Write it down. Here is a simple guideline.

1. Write your current workflow. Office workflow, from patient calling for appt, check-in to check-out. List your staff, and write down who does what and in what order.

2. Identify ‘gaps’ or ‘areas of improvement’ in your workflow map.

3. Potential pitfalls and fears in implementing technology.

Now, Prepare a Demonstration Script.

1. Take your most common encounter/patient visit. Look at a few finished visit notes.

2. De-identify the set of note(s) so that patient information is removed.

3. Send it to the demo person(s) – at the time of the demo, or just before so that they have enough time to review it, but not enough to ‘fudge’ their system. Also, send them or tell them your workflow.

4. Ask them to stick to the script. Only after that is done, they can show off their system with other ‘features’. But tell them what you care about and what you don’t.

5. Finally, ask them – ‘What would you do to improve my workflow and make my practice more efficient’? This is one of the most important questions, don’t skip it. It will tell you a lot about how this vendor approaches things.

Proper preparation converts hoping to reality

The Healthcare IT News article “Fighting Physician Burnout: How Tech Can Undo the Damage Done by EHRs” is enticing; it promises that healthcare information technology and EHRs can solve the burnout problem.

I have a different take on it. The physician burnout problem is not caused by technology per se; it’s about workflow and how technology is used.

As I read the article, standard concerns about healthcare information technology stood out:

• Software should not go down.
• Service should not be interrupted.
• EHR should be integrated with critical systems.
• Better document management is important.
• Information should be readily available and easily searchable.
• The information must be reportable.
• Communication within the practice is important.

There are many very good systems I’m aware of that do all of the above quite well. Many tech-savvy physicians have been using these systems, and despite all of this, these tech-savvy physicians complain of burnout — they complain of turning into data entry operators!

What is the real issue?

Efficiency must be measured in terms of the big picture rather than as just software and clicks. Physicians are a practice’s most important — and expensive — resource. Their every moment is valuable and must be spent taking care of patients. All other tasks can, and should, be delegated to staff who can utilize healthcare information technology to accomplish everything a physician needs for critical clinical decision-making.

What this means is using technology to have information at the physician’s fingertips and making the information available when and where he or she needs it; however, the physician doesn’t have to be the primary technology user to enter or pull data.

It’s all about the workflow

I’ve helped many physicians jump the hurdle of the EHR technology barrier. It is possible for the provider to deliver good care without becoming a data entry operator, but still take advantage of everything healthcare information technology has to offer. The provider can do all this with minimal keyboard and screen contact.

Workflow example

Provider walks into the exam room. Past notes, triage notes, vitals, results of orders, and radiology, are all available and displayed on the computer screen for the provider to review immediately. How that happens varies from practice to practice. The important thing is that the provider doesn’t have to spend time clicking or typing.

Provider spends time talking to the patient. It is important to note that the provider’s only task is to talk to the patient while maintaining eye contact.

As the provider talks to the patient, the nurse or medical assistant interacts with the EHR to enter the discussion’s pertinent details.

The provider has minimal interaction with the computer. Their interaction should be limited to selecting diagnostic and CPT codes and e-prescriptions, if necessary.

The provider goes to his or her office and dictates a personalized narrative into the EHR system. This should not take more than 60 seconds. Often, it takes fewer than 30 seconds.

The provider can quickly view the note and sign it.

The provider moves on to the next patient.

Some of you may argue that the provider cannot afford to have additional staff in the exam room. What I fail to understand is when it becomes acceptable to have a provider with a very high hourly rate perform data entry instead of a medical assistant. The above workflow may allow a provider to see one more patient per day, or to go home early, thus achieving a work-life balance.

Efficient medical practices use a combination of great technology and improved workflow. The above scenario allows all the advantages that EHR technology has to offer without converting a provider into a data entry operator.

I had written about how much you should pay for an EHR system.

I would like to talk about the concept of EHR pricing: Chinese menu versus nickel and diming. Some vendors are notorious for nickel and dining every little thing about their system. The reason I’m bringing this topic up is because sometimes we get confused between the 2 types of pricing.

We’ve all gone to Chinese restaurants and we know what a Chinese menu looks like: it’s long, it’s huge, but the idea behind this is that you pick what you want to eat. Similarly, you pick what you want in terms of EHR features and functionality versus just very high-level bundled packages like a prefix dinner.

This is perfectly normal because when you do your practice analysis in terms of what your needs are, you know what specific things you need in your system.

What bothers me most is when people start nickel and diming. For example, when you go to a Chinese restaurant you don’t want them to charge you extra for soy sauce, and you don’t want them to charge you for a cup or a fork – that is nickel and diming.

EHR system vendors say they are including text messaging and faxing, It is a cloud system so storage is included. They say that we will allow 100 faxes, 1 GB of data storage, and so on. That to me is nickel and dining. It’s very similar to your mobile/cell phone plans where they give you a certain number of minutes per month; they give you a certain amount of data per month.

They don’t have any more genuine unlimited plans where I don’t care how much you talk, I don’t care how much data you use. A flat fee that is predictable, is absolutely essential for business.

What I’ve seen typically is. There are at a high level probably 3 types of main bundles:

• Clinical/EMR module
• Billing module and
• Combined software

Within these, there may be many features that are probably included and you need to evaluate them carefully. There may be certain optional items, and these could be anything ranging from EPCS which is controlled substances electronic prescribing to text messaging.

Some people have good productivity tools such as digital pens, medical card scanners, and so on, and that, I can understand as optional.

Therefore when you’re comparing different systems and vendors what I want you to do is to start making a list of the things that are included and what different vendors want to charge.

Watch the video above to see how to compare EHR software vendors’ pricing.

They range from $0 (Practice Fusion) to $800 per provider per month. Most EHR systems charge a monthly subscription fee these days.

So, how much should you pay?

If you think all EHR systems are the same, buy the cheapest Certified EHR system. Right?

When you say ‘they are all the same’, what you really mean is that all certified EHR systems have the same ‘features’. i.e., they do charting, they store patient data, labs, ePrescription, ICD-10, CPT, and E&M coding, etc.

For Example, both iPhone and Android devices have all the ‘features’, yet you choose one versus the other. Why?

OK, so they are all NOT the same. 

Second Question: How much can you afford to pay?

Before we try to answer that, ask yourself this.

EHR should not be taken lightly. The negative impact is very critical. By implication, looking at EHR as a cost and expense is not correct. EHR must be a proper financial and investment decision. You wouldn’t hire a nurse that wants the lowest salary, would you?

Let’s break it down.

1. All EMRs are NOT the same.
2. Don’t go by Price. Don’t start a conversation with ‘how much’? You are not buying potatoes.
3. Prepare very hard and meticulously – as if you are starting a business.

Prepare very hard – as if you are starting a business

This is one element of your practice that, as I mentioned earlier, can have a tremendous impact on our business bottom line if you choose the wrong system and the wrong vendor. Here are some things I recommend you must do before you see any demonstration.

• Have a written document outlining the complete practice workflow.
• Have your staff write specific parts of the practice workflow that are inefficient and can be improved.
• Identify 5 cases that represent 80 – 90% of your patients (unless you’re a super-specialist where each patient is truly unique). Use these cases to benchmark systems. Share these cases with the vendor (de-identified) and ask them to walk you through these cases.
• Ask the vendor to show how they can bring improvement to your practice rather than focusing on particular features. There may be many ways to accomplish the goal.

And finally, determine a budget that you can afford and something that can bring positive ‘return-on-investment’ (watch the video below)

EMR Systems are NOT expensive.

Talk to your Accountant/CPA. Look at your Profit and loss statement and determine the distribution of costs. You may quickly find that you sometimes spend more than the monthly fee of an EMR on things that do not have such an impact on the success (or failure) of your practice.

And finally, don’t be afraid of spending slightly more than you can afford to get the maximum value and support from your vendor. It will pay off!

For most companies, businesses, medical practices included, success depends a lot on the team that you have recruited. It goes without saying that picking a winning team is crucial. The problem is we are very bad at it.

SAT is a bad indicator of college performance and even life performance. Yet colleges have to use it anyway. Somehow we keep on pushing our kids along the same path.

Professional sports spend billions of dollars every year to recruit what they think are the best players. Yet scouts continue to pick the wrong players. Having watched Moneyball we know that we tend to ignore useful data and rely too much on our instincts.

Selecting and choosing EMR systems is no different.

When we invite vendors for a demonstration do we even think about what was a criteria for their preselection? We may have gone by recommendation of a third party or a trusted friend. We allow somebody else to prejudge us. What we should really be doing, is to understand our internal needs first by talking to the entire team. Focus on prioritizing what is important and what is not.

It takes guts to stop prejudging because it feels like we’re giving up control. But, as far as EMR is concerned, we never had control did we?

Inspired by Seth Godin.