After a nationwide push to move from paper to electronic patient records, the next phase for some hospitals and physicians is a redo.
As of 2015, nine out of 10 office-based physicians, or 87 percent, had adopted some type of electronic health records system, more than doubling the rate of 42 percent in 2008, according to the Office of the National Coordinator for Health Information Technology. Among non-federal acute-care hospitals, four out of five organizations had adopted a basic EHR with clinician notes by 2015, the ONC reported.
For some organizations, changing EHR systems comes as a result of mergers or acquisitions, and the desire to coalesce around one system. And as some provider organizations grow, they need to switch systems because they outgrow the capabilities of the systems they have in place.
But a few organizations report changing systems because of dissatisfaction. A 2015 survey of 277 community hospitals from research firm peer60 found that more than half of those hospitals were unsatisfied with their current EHR, and 20 percent were planning to replace their EHR vendors. Physician frustration with EHRs also has been widely reported.
Replacement “is a common discussion,” says Michelle Holmes, principal, ECG Management Consultants. Holmes, who counsels clients involved in replacement projects, adds that many of those who evaluate a possible EHR replacement ultimately decide to optimize or upgrade their current system.
For those who go forward with a replacement, however, Holmes says there are four primary reasons for their decision:
- The system is no longer a good fit after a merger. Executives may opt to consolidate on an existing system or choose a new system to replace their existing systems.
- The system isn’t performing anymore, either because it can’t scale to accommodate growth or the provider’s needs exceed the functional capabilities of the system.
- The EHR is being discontinued.
- The vendor has lost credibility with physicians to such an extent that the only way to secure physicians’ buy-in for digitizing patient records is to select a new vendor.
For example, Edward-Elmhurst Health was created in 2013 by a merger between two organizations in Chicago’s western suburbs—Edward Hospital & Health Services and Elmhurst Memorial Healthcare. At the time of the merger, Edward had just switched its inpatient EHR from Meditech to Epic, while its outpatient operations had been on Epic’s software since 2012. At Elmhurst, its physicians also used Epic’s system, while its hospital used Meditech’s system. And nearby DuPage Medical Group, an independent multi-specialty practice with more than 560 physicians that primarily admits patients to Edward-Elmhurst, also used Epic’s EHR.
That’s why the new health system’s leadership concluded that consolidating on a system from Epic would not only provide operational efficiencies but also foster a consistent approach to patient care.
As Bobbie Byrne, executive vice president and CIO at Edward-Elmhurst Health, explains, “Having the same EHR system helps us say, ‘We are going to practice evidence-based medicine with the very latest information that is built into our records, and we do it regardless of the location that you present for care,’ ” she says. “It is about what is the most efficient way to raise the quality of care for everyone.”
Without disclosing the total project’s cost, Byrne says the health system spent “half as much” to install Epic’s EHR at Elmhurst than it had spent at Edward. By the time Elmhurst Hospital switched to Epic, Byrne notes that the data center infrastructure was in place, and her team was experienced at using the software. “They really know Epic well, and the features and functionality in the system. You can be so much more efficient when you are doing it the second time than when you are doing it the first time,” she says, adding that they completed the Elmhurst implementation at 5 percent under budget.
Out in California, executives at El Camino Hospital—with campuses in Mountain View and Los Gatos—concluded that they wouldn’t meet the requirements for Meaningful Use and value-based care if they stayed with the hospital’s legacy best-of-breed configuration, because of challenges of achieving certification for the variety of systems in use. It went live on Epic’s EHR, population health and billing systems in November 2015.
“This enables us to meet certain (Meaningful Use) objectives. With the new Trump Administration, we don’t know what will happen to Meaningful Use and MACRA and some of the other governmental regulations, but (the Epic system) places us in a great position to get the reimbursement we should receive. It also helps with population health initiatives, such as accountable care” because of better information integration and updated system capabilities, says Debbi Muro, interim CIO at El Camino, which has a long history with electronic records, and installed its first CPOE system in 1971.
Meanwhile, Adventist Health System, based in Altamonte Springs, Fla., took a different approach. It is replacing ambulatory platforms from four vendors with electronic health records and practice management modules and services from athenahealth, based in Watertown, Mass. But Adventist kept its hospital operations, medical oncologists and physicians involved in the health system’s organ transplant program on an EHR from Cerner. Cerner and NextGen Software were among the vendors of the ambulatory EHR systems that Adventist is replacing.
Adventist officials wanted a system that was “purpose built” for the outpatient setting, enabling staff members to become more efficient in patient care and billing operations, explains Jeremy VanWagnen, vice president of physician enterprise, continuing care and research IT systems in Adventist’s IT department.
For example, Adventist executives hope to improve the health system’s performance in patient portal adoption, fees collected at the time of service and lag time in entering charges for claims. Adventist also hopes to decrease the time physicians spend after hours finishing their work in the EHR, explains Holmes, who is a consultant to the project.
Whatever the reasons, replacing an existing EHR presents many challenges, although IT departments benefit from their earlier experience configuring, deploying and supporting electronic patient records.
“The client organizations have a much better understanding of what works or didn’t work both from an implementation and ongoing support perspective,” Holmes says, adding that health systems ought to view the replacement project as an opportunity to take a step back and evaluate “all the different things that you could potentially include in a replacement project,” she says, including technical and operational factors.
Data Migration and Integration
One common issue in replacing an EHR is deciding what data to migrate to the new system and what to do with the data that remains in discontinued systems.
When Elmhurst Hospital went live on Epic’s EHR on Oct. 1, 2016, its staff had access to four years of data in the new system and read-only access to the older data remaining in Meditech. Byrne says the health system typically converts two years of data, but she went with the longer time span in this case so that the data in Epic would go back to the same date—July 2012—at Elmhurst, Edward and the ambulatory settings. “Otherwise, it is confusing,” she says.
At Adventist, which is converting about 1,400 providers in eight states to athenahealth, the project team wanted to minimize the amount of data reentry that clinicians would have to do.
Based on feedback from physicians, Adventist decided to move data on patients who had been seen by a provider in the last three years. This data included problem lists, allergies, histories, immunizations, vitals and office notes, as well as data on demographics, insurance and referring physicians.
After concluding that there were too many discrepancies in medication lists among the various EHR platforms, Adventist did not move that data. Instead, providers pull information about patients’ recent prescriptions from Surescripts, a technology company that supports data sharing about prescriptions and other medical information. During office visits, providers work with patients to build comprehensive medication lists, using the data from Surescripts as a starting point.
With so many systems remaining from its best-of-breed approach, El Camino Hospital’s project team members had hoped to use an archiving solution to consolidate data that they did not move to Epic. “We weren’t able to achieve the goals that we had hoped. We have stopped that project,” Muro says.
Instead, the IT department gave users read-only access to data that they may look at occasionally, such old lab values, while removing access to data they no longer need, such as from surgeries that occurred some time ago. In either case, El Camino’s IT staff has complied with regulatory requirements about retaining data and also has reduced costs significantly.
Muro expects the hospital to save more than $10 million over five years in total maintenance costs by decreasing the number of production systems and interfaces. Indeed, the IT staff reduced the number of interfaces by 75 percent.
When it comes to interfaces, Adventist is going in the opposite direction. Its staff developed a plan for sharing data between Cerner on the inpatient side and athenahealth on the outpatient side.
“We provided a group of interfaces for those feature functions that were appropriate and safe, and would be used on an ongoing basis by the providers,” VanWagnen says. Adventist created bi-directional data sharing for many data elements, such as for lab and radiology orders and results or demographic data—but not for everything. For example, surgeons cannot pull up automatically in the hospital’s EHR patients’ history and physical data that they had already documented in the ambulatory system.
“There are lots of things that are very much not ideal. We need to work with our vendors to go do that next phase of work. We are excited about it—drawing the systems closer to each other to help with safe and efficient care, but it is a journey,” VanWagnen says.
Communication, Training and Support
Technology issues aren’t the only hurdles to overcome. Communication and change management also require careful planning and execution. “I am big advocate in projects like this in actually engaging the organization’s marketing and communications department to help with that,” Holmes says.
Adventist took her advice. VanWagnen says Adventist’s corporate marketing team has been involved in the project from the beginning and helped create a multi-faceted approach to communication and change management, including a project title, “Operation Athena,” and logo.
VanWagnen and a team also traveled to every medical group over a two-month period to talk about the decision-making and implementation processes. The team also bought and rebranded an event-management app, enabling users to respond to surveys, post pictures and comments, and review schedules and documents. Adventist provided users with desktop and smartphone versions of the software. “It was one of the primary vehicles to both talk and listen and take the temperature out in the user base by surveying on a regular basis,” VanWagnen says.
Despite meticulous preparation before replacing an EHR, training and support issues crop up after a go-live date.
Muro says the El Camino’s IT department underestimated training costs by about 20 percent, but it recouped the cost overrun because the entire project came in under budget. She says the department miscalculated the amount of time nurses would spend practicing in the test environment before the go-live date and how many employees would use overtime hours to attend training sessions.
El Camino’s IT staff also realized quickly that clinicians needed additional coaching to help them make decisions about what external data they should incorporate into patients’ records at El Camino. In less than 12 months, El Camino Hospital shared 2 million records with organizations in 43 states that had an EHR from Epic.
“We had to stop and train our users in how to bring in the relevant data,” Muro says. “That was an aha moment.”
Adventist’s “Operation Athena” team has been tweaking the process continuously as it rolls out the ambulatory system in six waves. It is scheduled to complete the implementation this year.
For example, during the first wave, some users couldn’t access the information they needed to do their jobs because they didn’t have the correct security position. For the second wave, “we did a better job communicating what our security positions were, and what they would be able to do, and how those related to their previous positions,” VanWagnen explains. Adventist also made sure users logged into the system before their go-live dates to see exactly what information they’d be able to access.
“We learned a lot after the first wave about training and support, pre-activation prep, testing, and what it takes to support the application,” VanWagnen says.
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