Nice post on TempDev.

Who Should Conform: You Or Your EMR? encapsulates in one pithy question, the essential nature of the IT dilemma at the provider level.

Usually, it takes a more direct form: Why the hell should I conform to the EMR system — the machine — when it’s the proper role of technology to make my life easier?

Who’s the boss here, anyway?

The answer, of course, is that you’re asking the wrong question.

Everyone’s The Boss

There’s no question that you, as a healthcare provider, are more important than the thousands of lines of software code.

In an ideal world, the system would conform to you, and your office mate, and your colleague across town, seamlessly and instantly, no matter how different your practice styles were.

In the real world, an EMR system comes “out of the box” a certain way — hopefully, close to the way you practice. It’s never a perfect fit, however, so someone has to tweak it to fit your particular needs, like a tailor. That’s going to be you, your tech support, or both.

As I’ve alluded to in previous posts, EMR systems are complex beasties. They have to be, in order to perform the myriad tasks demanded of them:

• prescribing and e-prescribing
• documenting patient visits
• ordering labs and radiology studies
• referring to your cadre of specialists
• inter and intraoffice messaging
• handling phone calls and email-type communications
• and so on

Doctors are complex beasties, too.

Admit it: do you practice in exactly the same way as your same specialty colleague? Use the same verbiage, refer to the same people, order the same labs for a given condition, follow-up patients with the same frequency?

Every doctor on earth wants an EMR to conform to their weird demands individual peculiarities (it’s called “customization”). Every EMR vendor in existence wants to sell a system accommodate every single doctor and medical practice (it’s called “market share”). What could be more natural than a mismatch?

Who gets to be the tie-breaker?

Usually The MSO, Sometimes The Vendor, But…

If you’re lucky, you’ve got an MSO or a healthcare management group on your side, updating your software, maintaining your servers, and otherwise letting you focus on the practice of medicine. The MSO will also tailor the system to better fit you, adding certain options, hiding features you don’t use, etc.

If you’re very lucky, if that’s the right word, the vendor will do that adjusting and tweaking for you.

For the sake of argument, assume that the tweaking and tailoring is being handled well by whichever organization.

Who’s the boss, really?

1. You? The nominal raison d’etre of the whole enterprise, Dr. Fron T. Line?
2. The MSO/vendor? The ones juggling all those incredibly numerous, complex interlocking lines of code?

If you say “Jump!” shouldn’t they say “How high?”

If they say “Can’t do that, it’ll take months and hundreds of thousands of dollars,” should you say “Okay, just thought I’d ask?”

Bottoms Up Wins Over Top Down, Always

If you’re looking at things from the standpoint of a doctor, who needs and therefore expects, demands that the system bend itself to your will, you’re seeing matters from a top down viewpoint. This is how things should be, it’s the principle of the thing, this is a matter of right and wrong. Your way, of course, is the right way, and everyone who isn’t helping you is an evil minion of Darth Vader.

The bottoms up viewpoint is much simpler, and less prone to argument or discussion over matters of philosophy, ethics, or epistemology.

Who’s the boss? He Who Can Kill The Project, that’s who.

If the infrastructure of the practice implodes, everybody loses, end of line.

That’s Okay, Pa, We’re Gettin’ Hitched In The Morning

Something they didn’t tell you, when you signed on for your EMR: you were getting married.

For better or for worse, in sickness and in health, you will be joined at the fingertips, for 8+ hours most days of the week, for the rest of your clinical lives.

So, you can do things the hard way, or you can do them the shoot-me-now way.

Nobody said it would be a cakewalk — melding an EMR and a medical practice takes work and constant upkeep. There are ways of making things easier, but get over yourself, already. Sitting smugly in a corner and telling your MSO/vendor that they’re just not getting it right, it’s their job to make the system lick your shoes, is about as helpful in this partnership as it would be with your spouse. And will end just about as badly — for you, your MSO/vendor, and your patients.

Luckily, both you and your MSO/vendor have a lot at stake, and are thus motivated to make things work (especially with an MSO that exists to support practices).

Who should conform: you or your EMR?

Both of you, of course, to do whatever it takes for great patient care while preserving your sanity.

You’re not trying to win first prize in the fingerpointing contest. If the practice flies apart, no one will care “who was right.”

Did You Know? from Amybeth on Vimeo.

Once in a while, there’ll be an info source that seems to have nothing to do with EMR’s, but is so mind-blowing and actually related that it must be acknowledged.

Hence: Did You Know?

Why Do YOU Need To Know This?

Because you need to pat yourself on the back — any chance you get — about why getting into EMR’s was a Good Idea.

As the video and this other one point out: because without moves like getting on board with electronic medical records, the World…

Will…

Leave you in the dust.

Special thanks to Brandon Betancourt, of Pediatric, Inc., for bringing this video to light.

Back in the day when I was a burgeoning kendo student, I read an account about a visiting fencing master.

The writer, an established member of a kendo club, was looking forward like everyone else to the visit of this celebrity sensei. While having practiced kendo for nearly seven decades, the guest was appallingly fast, and had a reputation for winning known throughout Japan. He was, in a word, amazing, and every bit as impressive in person as his record suggested.

When the guest asked the writer to practice with him, the club member was practically beside himself. What special techniques and feints would he be privileged to witness? What insights into timing, distance, and psyching-out your opponent would he be party to?

“I’d like to work the overhead strike,” the guest requested.

WTF??? thought the writer.

“Yes,” the master said, wiggling his bamboo sword experimentally, “I think I’ve almost got the hang of it, now.”

First Walk, Then Fly, Grasshopper

Mixed martial arts metaphors aside, it’s always a Good Thing to return to the essential core of EHR rollouts: getting physicians up to speed with the new technology.

No matter how many new features a given product has, attention to this basic workflow training matter will never be misguided.

If you can’t be too rich or too thin, you can’t possibly be too adept at documenting patient encounters.

The temptation can be great, at the organizational level, to focus on high-end developments. That’s natural: it’s an organization’s “job,” so to speak, to take the long view:

• data mining
• pay for performance
• Medicare compliance and audit proofing
• RAF coding

All the things that the future of medicine and medical practice survival will depend upon.

But docs…docs just want to survive the day.

Take It In Steps

There are 3 distinct steps or stages to EHR competency, and — you guessed it — individual doctors focus on one end, while organizations focus on the other:

1. Stage 1: Finish the day, notes done, nothing taken home, no reassembling notes at day’s end
2. Stage 2: Communicate efficiently with patients, and regularly update chart data
3. Stage 3: Be a Power User, whatever that means to you, but including strategic feature usage

Neither focus is wrong. Physicians need to feel comfortable with the daily grind basics before they’ll give a hoot about more advanced features. Organizations need their providers to migrate to more advanced features, which ultimately make the groups more competitive and viable in a chaotic health care market. Everyone needs to get comfortable with the full spectrum, which makes intrinsic sense.

What’s debatable is how best to accomplish this.

The One Ring To Rule Them All

In the next post, I’ll break down an approach to Stage 1 competency that’s worked for me, my colleagues, and a number of small group primary care physicians. Sometimes it just takes a trail of breadcrumbs, to help you find your way through the twisty turny forrest.

Meanwhile, chew on this, the central key that unlocks all the EHR hurdles a doctor will ever face, a secret that is literally worth thousands in medical IT consultant fees.

Get this, and you will pass “the hump” between you and effective, efficient EHR use, and the medical record will be your tool and aide, no longer your tormentor.

Ready?

Really ready?

It’s All About Attitude

Not Medicare e-prescribing, not patient portals, not customizability, not intuitive interfaces. And, no, not about INTEROPERABILITY.

Nope.

Those are external bells & whistles. Beautiful, no question, and jewels beyond price, to physicians and groups ready to use them.

But before you went electronic, you were documenting on paper, and not doing too shabbily.

The magic is in your attitude — how you look at your documenting world and choose to do whatever is necessary — not the software, nor the electrons, nor the pen and ink, for that matter.

YOU decide when you’re going to suck it up on any given day, and do what’s necessary, even if a bit tough on you, with a smile. Or when you’re going to carp and moan with the rest of the chorus.

There’s The Carrot, And There’s The…

Face it: presented with a choice, most of us will choose the easy way out. And it’s easy to go on about how hard it is to transition to an EHR from paper (true), how your MSO isn’t instituting obvious improvements as fast as you’d like (probably a good reason, they ain’t dumb, you know), or how your tech support sucks (valid critique, time to take some major action).

What seems hard, but is actually just as easy — thanks to an attitude adjustment — is having to make due with no choice in the matter:

1. You’re going to adopt an electronic record system — ours — or you can kiss your contract goodbye, there’s 5 guys who want your spot.
2. The system you get is the out of the box system, no tweaking or fine tuning, you gonna ask me a valid question?
3. Our tech support has had its wrist slap, we’ll watch them, now get back to work and do your job while they do theirs.

Fun? No, but it’s remarkable how many large and quite successful mega groups, nationwide, operate daily on exactly these principles. Human beings can “adapt” quite well (in this case, get on with business) when there’s no room to flap their arms and squawk to their buddies.

Is every single user having a meltdown with your system? No? Is there a goodly number of folks who are working with it just fine, thank you?

Hmmm…

I Owe It All To The Martial Arts

Nobody deserves to be abused, and being bound at legal gunpoint to a product that is broken to bits is absolutely grounds for piping up.

But barring that, take a lesson from any of the Asian martial arts.

These other phenoms did it, and so can you.

Your system the real deal, proven, not some fly-by-night invention? Check.

Other students ahead of you looking pretty good with the school? Check.

Good instructors present, going to be there for you, living examples of how well the system can work? Check.

So get with the program, already. Welcome, your first lesson starts with your next visit, and it begins and ends with the overhead strike.

The rest is up to you.

To borrow a line from an old Paul Newman film, “what we have here is a failure to communicate.”

Whether you’re a physician, an office manager, an office staffer, or an EMR vendor/service provider, if you’ve ever sighed deeply or gritted your teeth, there’s a certain eye-to-eye linkage that just isn’t happening.

The stakes are too high to mess around: at the top level, everyone really does want an EMR adoption to succeed. Nobody can afford to let it fail.

Why can’t we all just get along?

The ONE Key Thing

One of my favorite books describes what the most persuasive being of all time used as a deal closing question: Is there anything I can say that would change your mind? References to Lucifer aside, this is one of the most critical and overlooked issues in marketing, or the art of persuasion:

To be successful, don’t make what you think people want and try to sell it to them; ask what they really want and then provide it to them.

The key word here is “ask.”

Many of us come from hard-won positions of authority. You know what you know, by dint of hard work, navigating the treacherous waters of office politics, or years of carefully accumulating critical data.

And when someone asks you a question that they really ought to know better than to ask, what happens? Your eyeballs cross — especially if it’ll cost you time, sweat, or money to deal with.

A natural reaction. But exactly the wrong one, if you want your implementation to succeed.

The Wrong Vibe

The problem is, everyone involved in the implementation process thinks they know what the real problem is, and the finger is never pointing at themselves.

• Office staff are fed up with templates that repeatedly hang at the same spot.
• Physicians are frustrated at a workflow that in no way parallels their natural habits.
• Medical directors are flustered at being nickel-and-dimed for support services that they’ve already bought.
• EMR support staff are tired of wrangling with third party hardware and software services outside of their own control.

Everyone is right, from within their own section of the world.

But how far is anyone going to get, saying “You just don’t get it, do you?”

Internet infopreneurs learn what works faster than anyone I know — because they can change their information marketing quickly if need be, and if something works, they earn money in a hurry, and if it doesn’t, they starve.

And Important Lesson #2 they live by:

You won’t make any long term, mutually beneficial relationships by pissing people off. Telling them you know better than they do what’s good for them is a prime formula for doing just that.

Your tech support guy is very probably right when he says the modification you desire would crash your system; you telling him “it’s not the way I do things” isn’t going to make the silicon chips grow wings and fly. If you’re a techie and your users tell you your new upgrade will multiply their workload by a factor of 10, insisting on its other benefits will not make their repetitive tasks any easier.

Even if you actually do know better than the other guy what the problem is — especially when you know better — you need to put on your humble, “Let us reason together” hat. Or you’ll be spending a lot of time staring at each other over crossed arms.

The Natural, Obvious, Best Vibe

Think back to the last time you were really in a bind — time’s up, no resources in sight, you’re totally screwed — and you suddenly got saved and you were so grateful, you wanted to kiss your savior right there and write them a letter of recommendation that’d get them promoted to the vacation spot of their choice, forever.

• Did your savior know their business? Of course.
• Did they lord it over you? Probably not.

They probably made it look easy, no trouble at all, like this was what they were there for, they did this kind of thing all the time.

They probably put you at ease, this will work out, we can handle it.

Most important of all, they quickly identified and acknowledged your fears, and made resolving them their immediate top priority.

Would you go back to them over anyone else, if you needed assistance in the future? Would you recommend them to your friends and colleagues? Would you be well-disposed to their organization, because of the incredibly helpful human face they gave it that day?

See where this is going?

The Hat You Wear Should Be The Other Guy’s

You may not choose to wear that Ultimate Service hat; maybe your momma never showed you how to be that nice, or you’ve forgotten how. Perhaps it’s not entirely appropriate, in your position in the organization.

But even from a purely mercenary standpoint, you need to know what works for the long haul. In the short term, it’s enough to know your material — just barely. But for ongoing relationships and word of mouth buzz, you want people to be deeply, totally convinced of your awesomeness.

Ultimately, we’re all of us in a service industry, either as health care providers to patients, or tech support for the providers. Being thoughtful, clear, and pleasant will always be useful both for giving good service as well as receiving better service yourself.

And if you don’t quite know how to do that, just ask: “What can I do to help you out of your difficulty?”

Plain and simple, most medical professionals are dusty old farts when it comes to the Internet and modern technology.

You know: what everyone else is using to learn and talk about current events, their health, their job prospects, their friends and coworkers…the latest developments in their respective fields…

The critical stuff.

Health and Human Services Director, Michael Leavitt, recently put it like this:

It’s obvious that the medical establishment has yet to complete the jump to the Internet Age. Our health care system has fallen behind every sector of our economy, from car repairs to manufacturing to air travel, for no good reason. There’s something wrong when you can walk away from a bank or mechanic with a detailed, easy-to-read printout but, when it comes to your health, you’re left hoping the pharmacist can make out the doctor’s handwriting.

He was referring specifically to the lack of EMR adoption in 90% of doctors’ offices, but the problem goes way beyond that. For the vast majority of American physicians, it’s an Internet mindset problem of epidemic proportions.

If you’re reading this, you’re by definition ahead of 99% of our profession. You know what a blog is, what an EMR can do, and you’re possibly even familiar with terms like RSS, social networking, and New Media.

Even if you’re not fully on EMR just yet, you likely communicate via email, use computers in your daily personal life, and garner information about The World via online news services or feed readers.

Many of our colleagues — you don’t want to know how many — still think of the Internet as a collection of fancy, online Smith Corona typewriters, and EMR as one of those fancy typewriters off in a room somewhere. If this vaguely sounds familiar, please note: this way of thinking was the vogue about 20 years ago.

Check out the following YouTube video, and compare your tech competence to some savvy power users. Only, this isn’t about how businessmen in Belgium communicate and think via the Internet, or surgical chiefs in Hanover, or even Silicon Valley geeks.

It’s about how typical American college students — the cream of the world’s crop, the pinnacle of human intellectual development — have integrated the Internet, social media, and computer technology in general into every aspect of their lives, of which studying is (still) a small part.

Sobering, yes?