Has Electronic Health Record Replacement Failed?

The following is a guest blog post by Justin Campbell, Vice President, Galen Healthcare.
Justin Campbell
A recent Black Book survey of hospital executives and IT employees who have replaced their Electronic Health Record system in the past three years paints a grim picture. Respondents report higher than expected costs, layoffs, declining revenues, disenfranchised clinicians and serious misgivings about the benefits of switching systems. Specifically:

  • 14% of all hospitals that replaced their original EHR since 2011 were losing inpatient revenue at a pace that wouldn’t support the total cost of their replacement EHR
  • 87% of hospitals facing financial challenges now regret the decision to change systems
  • 63% of executive level respondents admitted they feared losing their jobs as a result of the EHR replacement process
  • 66% of system users believe that interoperability and patient data exchange functionality have declined

Surely, this was not the outcome expected when hospitals rushed to replace paper records in response to Congressional incentives (and penalties) included in the 2009 American Recovery and Reinvestment Act.

But the disappointment reflected in this survey only sheds light on part of the story. The majority of hospitals depicted here were already in financial difficulty. It is understandable that they felt impelled to make a significant change and to do so as quickly as possible. But installing an electronic record system, or replacing one that is antiquated, requires much more than a decision to do so. We should not be surprised that a complex undertaking like this would be burdened by complicated and confusing challenges, chief among which turned out to be “usability” and acceptance.

Another Black Book report, this one from 2013, revealed:

  • 66% of doctors using EHR systems did not do so willingly
  • 87% of those unwilling to use the system claimed usability as their primary complaint
  • 84% of physician groups chose their EHR to reach meaningful use incentives
  • 92% of practices described their EHR as “clunky” and/or difficult to use

None of this should surprise us but we need to ask: was usability really the key driver for EHR replacement? Is usability alone accountable for lost revenue, employment anxiety and buyers’ remorse? Surely organizations would not have dumped millions into failed EHR implementations only to rip-and-replace them due to usability problems and provider dissatisfaction. Indeed, despite the persistence of functional obstacles such as outdated technology, hospitals continue to make new EMR purchases. Maybe the “reason for the rip-and-replace approach by some hospitals is to reach interoperability between inpatient and outpatient data,” wrote Dr. Donald Voltz, MD in EMR and EHR.

Interoperability is linked to another one of the main drivers of EHR replacement: the mission to support value-based care, that is, to improve the delivery of care by streamlining operations and facilitating the exchange of health information between a hospital’s own providers and the caregivers at other hospitals or health facilities. This can be almost impossible to achieve if hospitals have legacy systems that include multiple and non-communicative EHRs.

As explained by Chief Nurse Executive Gail Carlson, in an article for Modern Healthcare, “Interoperability between EHRs has become crucial for their successful integration of operations – and sometimes requires dumping legacy systems that can’t talk to each other.

Many hospitals have numerous ancillary services, each with their own programs. The EHRs are often “best of breed.” That means they employ highly specialized software that provides excellent service in specific areas such as emergency departments, obstetrics or lab work. But communication between these departments is compromised because they display data differently.

In order to judge EHR replacement outcomes objectively, one needs to not just examine the near-term financials and sentiment (admittedly, replacement causes disruption and is not easy), but to also take a holistic view of the impact to the system’s portfolio by way of simplification and future positioning for value-based care. The majority of the negative sentiment and disappointing outcomes may actually stem from the migration and new system implementation process in and of itself. Many groups likely underestimated the scope of the undertaking and compromised new system adoption through a lackluster migration.

Not everyone plunged into the replacement frenzy. Some pursued a solution such as dBMotion to foster care for patients via intercommunications across all care venues. In fact, Allscripts acquired dBMotion to solve for interoperability between its inpatient solution (Eclipsys SCM) and its outpatient EMR offering (Touchworks). dBMotion provides a solution for those organizations with different inpatient and outpatient vendors, offering semantic interoperability, vocabulary management, EMPI and ultimately facilitating a true community-based record.

Yet others chose to optimize what they had, driven by financial constraints. There is a thin line separating EHR replacement from EHR optimization. This is especially true for those HCOs that are neither large enough nor sufficiently funded to be able to afford a replacement; they are instead forced to squeeze out the most value they can from their current investment.

The optimization path is much more pronounced with MEDITECH clients, where a large percentage of their base remains on the legacy MAGIC and C/S platforms.

Denni McColm, a hospital CIO, told healthsystemCIO why many MEDITECH clients are watching and waiting before they commit to a more advanced platform:

“We’re on MEDITECH’s Client/Server version, which is not their older version and not their newest version, and we have it implemented really everywhere that MEDITECH serves. So we have the hospital systems, home care, long-term care, emergency services, surgical center — all the way across the continuum. We plan to go to their latest version sometime in the next few years to get the ambulatory interface for the providers. It should be very efficient — reduced clicks, it’s mobile friendly, and our docs are anxious to move to it,” but we’ll decide when the time is right, she says.

What can we discern from these different approaches and studies?  It’s too early to be sure of the final score. One thing is certain though: the migrations and archival underpinnings of system replacement are essential. They allow the replacement to deliver on the promise of improved usability, enhanced interoperability and take us closer to the goal of value-based care.

About Justin Campbell
Justin is Vice President, Strategy, at Galen Healthcare Solutions. He is responsible for market intelligence, segmentation, business and market development and competitive strategy. Justin has been consulting in Health IT for over 10 years, guiding clients in the implementation, integration and optimization of clinical systems. He has been on the front lines of system replacement and data migration and is passionate about advancing interoperability in healthcare and harnessing analytical insights to realize improvements in patient care. Justin can be found on Twitter at @TJustinCampbell

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  • My grandmother could have predicted the outcome

    “Surely, this was not the outcome expected when hospitals rushed to replace paper records in response to Congressional incentives (and penalties) included in the 2009 American Recovery and Reinvestment Act.”

    i.e. haste makes waste

    Question: How many of the folks who drafted up the legislation had worked in hospitals/clinics?

  • “84% of physician groups chose their EHR to reach meaningful use incentives”

    And therein lies the problem. They weren’t educated on how to shop for an EMR with features that would best suit their needs. As a result, they were at the mercy of salespeople.

  • Agree completely. HCOs felt rushed into decision to comply and ensure they achieved incentives and as a result, drove EHR replacement frenzy as the original purchase did not best fit the needs of the group.

    That said, it seems like HCOs have learned their lesson with EHRs as the PHM software market really has yet to take off and remains very fragmented. It seems that many HCOs are gun-shy and are tackling pop health projects without purchasing IT tools specific to the task.

  • Mr. Campbell,

    You raise a number of very important points in your guest article. The findings from the Black Book Study truly are grim, however, to solve them does not require ripping and replacing the currently implemented systems or trying to unify technologies across all clinical areas. To do so requires us to look at the problem from a different angle; one that has proven successful in other industries; middleware.

    We will not find a steady state in health IT, but a continually evolving and expanding landscape where technology enhances care delivery and wellness promotion. If we accept the premise that technology will continually change, we need to design and implement a system that can respond to change and create synergies with implemented legacy systems.

    The service oriented architecture using middleware goes beyond just connecting data and systems; it brings about capabilities where one can develop new solutions, processes and messaging capabilities not currently possible. This technical model has been proven in the financial sector to standardize and accelerate transactions and in other industries where processes have been designed and data has been collected in legacy databases.

    We entered the healthcare IT era with EHR’s to collect and store patient, process, quality and other data. In the process, we have learned a great deal of what additional information in capabilities we require to effectively take care of patients. Our understanding of this information will continue to expand necessitating the creation of new technical tools to help us stay at the forefront of patient care. Middleware brings the potential to solving the challenges of healthcare being faced today as well as allowing for the development of the solutions that are yet to come.

    Taken with this perspective, the concerns raised by the Black Book Study should not cause fear of where to come up with the funds to replace the implemented systems, but instead to inspire optimism of how to tackle the problem from another, more cost effective and scalable way.

  • Donald,
    Do you think that the implementation of high quality middleware will make it so we won’t replace EHR systems or do you think it will make it easier for us to change systems?

  • Hello John,

    Yes, one of, but not the only potential of using a middleware solution for EHR’s is to address the problem of interoperability. The cost of removing a currently implemented EHR and replacing this with another is not only a financial burden, but also a system-wide strain on a hospital along with issues of training and frustrations for healthcare professionals.

    Although middleware can be used in the transitioning from one EHR to another, it is much more beneficial to use it to connect disparate systems. In addition, middleware brings the potential of developing an ecosystem of applications that can be specialized for given situations, patients or specialties while interacting and interoperating with different systems and databases.

    Currently, the development and sharing of such applications is not feasible given the numerous different EHR’s currently in use, all with different ways to access and develop upon. Middleware serves as a connector layer between the data stores (EHR’s) and the user interfaces/access points into the information. By mapping the way data is retrieved and stored into any number of systems and EHR’s, and providing a standard API for developers and hospitals to use, development becomes more stable, consistent, scalable. It is also cost effective while at the same time bringing in a solution to connect old and evolving technologies.

    Hope this helps to address your question. If we look at the big picture of health IT, we need to design a system where old and new technology can co-exist while also enhancing and easing development to meet the needs of our patients and the professionals who care for them.

    Middleware provides the means to improve upon that which is currently implemented in a cost effective and rational manner. If we cannot access and add to a patient’s record, bring along automation where appropriate and allow creative people to bring new solutions into the health IT ecosystem, the improvements will be slow and expensive.


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