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An Alternate Approach to Avoiding Costly EHR Implementation Mistakes


Want to avoid costly EHR mistakes at your medical practice? I proffer the following, which I call the 'Order-of-Magnitude Heuristic.'

These are situations in which an exhaustive search for an answer that is probably correct is impractical. The best one can do is to make an educated guess, use common sense, or identify an analogous situation for which a solution is known. When turned into rules-of-thumb that can be applied to similar problems, you have a heuristic.

When building a house, the floor joist size depends on the span and the load. For example, "…half the span plus two. First, round the clear span of the floor joist up to the nearest foot, and divide by two. Then add two to the answer. This will give you the depth (in inches) of the required floor joist."

One reason EHRs cost so much is that people expect them to cost a lot. They are big and complicated -almost unimaginably complicated. What mere mortal could design one?  The proof? None of your professional friends managing similar organizations have attempted to develop one. They have all bought one, and paid a lot. With this preconception, when the bids come in at some astronomical price, you are not surprised. It's as you suspected all along. These babies are really expensive.

Let me suggest an alternate approach. It does depend on you having a clear idea of what you want to do, and I don't mean something nebulous like: Our goal is to get the incentive money and comply with all the mandates. I mean specific things like:

• We want to keep the time a doctor spends charting a visit under two minutes; or

• We want to eliminate duplicate recording of physician orders in the treatment plan and in the order entry system; or

• We want to treat the patient's time, as well as the doctor's time and the equipment, as limited resources when scheduling so that we don't make conflicting appointments for the patient that have to be changed later; or

• We want to give our charge nurses an integrated view of all the orders for all the patients so that they can prioritize them by patient acuity rather than by which doctor screams the loudest.

Once you have specific objectives then give yourself a budget of $10 and ask: Can I solve this problem for $10? Sometime the answer is yes. For example, a study published in JAMA found that "Displaying poster-sized commitment letters in examination rooms [about $10] decreased inappropriate antibiotic prescribing for [acute respiratory infections] ARIs." Usually $10 won't do it, so try again with $100. For $100 you can put a colored line on the floor. For $1,000 (maybe) you can install a door or a pass-through window to ease the flow.

For $10,000, small stand-alone computer systems are possible. Remember that  an order entry and inventory system for a restaurant can be had in that price range. How is that different from ordering and tracking supplies in the ER?

If you haven't solved your problem by the time you get to $100,000 to $1 million, you will have thought of dozens of possibilities. It will begin to seem that you have an unlimited budget. It will be hard to imagine what you could not do with it. I simply cannot fathom how anyone could consider billion dollar price tags to be anything than total insanity - but then, I'm a cheapskate. I wouldn't spend $2 million to chase a $1 million incentive payment and then have the project fail, like one that I know of in the Midwest.

I call this the "Order-of-Magnitude Heuristic." Start with a ridiculously small initial budget; it forces you to think outside the box. You will find that solutions will present themselves that address your real requirements more directly, cost less, and have a higher success rate. More success because each project is smaller, simpler, has fewer dependencies, and is targeted at those who need it. It will also make you a more intelligent consumer, should you decide to buy. Buy only what you need and only as much as you need. Technology is changing. Prices fall. You can't possibly implement a huge system all at once, so don't try. Spread out the acquisitions. You will learn things as you go that will totally change your view of what you need and if you haven't locked yourself in to a monolith, you're free to change directions. A vendor is a means to get what you want. Avoid being the means by which they get what they want - your money.

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