Ripping and replacing an electronic health records system that cost millions of dollars to purchase and implement is a project many providers dread-yet they do it.

In 2013, 305 hospitals switched EHR vendors and 62 changed their EHR systems but did not change vendors, according to the HIMSS Analytics Database. The year before, 434 hospitals switched their EHR vendors and 68 changed their EHR systems but did not change vendors.

What would lead a healthcare organization to take such drastic action?

For providers, it's often the feeling that a functional or technical requirement simply can't be met by their current EHR, according to Michelle Holmes, a principal at ECG Management Consultants. Holmes says it also could be a user interface need, a new specialty that is not supported by an existing EHR, or certain reporting requirements for a quality program.

"It could be that the vendor purported that they could meet that requirement when the EHR was sold, and after months or years of trying it just turns out that it's not the case-which certainly happens," she says. "Or, it could be that there's a new requirement that didn't exist at the time the EHR was originally selected."

There are other motivations as well. Consolidating many systems around one EHR, replacing an aging and obsolete EHR with a newer system that is more cost-effective, and a feeling that an EHR vendor is not a leader were all cited as reasons for switching out a system, according to a report published last year by KLAS on the acute care EHR market. There also are cases where hospitals are satisfied with the functionality and usability of legacy products, but don't want to be one of the last customers using the product.

And it's not just hospitals that are replacing their EHRs.

In a separate 2014 KLAS report on ambulatory EHR perception, more than a quarter (27 percent of 406 practices) indicated they were considering a potential EHR change. In fact, the research firm asserts that many ambulatory providers are moving on to their second or even third EHRs.

Smaller practices are driven to change over usability issues, poor support and cost constraints, according to KLAS. Midsize practices report switching EHRs for usability reasons or to standardize from multiple EHRs to fewer. As practice size increases, the KLAS report found, so does likelihood of a replacement (24 percent of small practices; 32 percent of large practices).

Reaching for better usability

John Kenagy, currently chief information officer at Legacy Health, a nonprofit health system covering Oregon and Southwest Washington, has served as CIO for three major healthcare organizations over the past decade and all three-including Legacy-have switched their EHR vendor to Epic, mainly due to the previously installed system's poor usability.

"I love being on Epic and I think it works better for our organization," says Kenagy. "But I can't say that I don't have physician complaints every once in a while about the requirement to document and doing order entry." Epic declined to comment for this article.

However, it's no secret doctors frequently complain that EHRs consume more time than they save, with poor information display and navigation that impedes rather than facilitates providers' work. And Kenagy adds that reducing the number of clicks it takes for doctors to perform tasks is critical to the good design of an EHR. And the EHR has got to get this right.

Bringing in a new EHR means "a massive amount of change and change is tough for anybody, but I think we are putting clinicians through more change than most people in most industries," says Rich Berner, president of Allscripts Sunrise, which offers the Sunrise acute/ambulatory EHR. "Physicians, in particular, feel like they are doing a ton of data entry and extra work and maybe not immediately seeing the benefit of it."

The need for smart user interfaces

The American Medical Association makes the case that the design and implementation of EHRs generally do not align with the cognitive and workflow requirements of physicians within and across specialties and practice settings. The "right" EHR can help free up physicians to focus on patient care. However, poor EHR usability is distracting to physicians, who are forced to focus on technology rather than on their patients, and it's a main driver for providers switching out EHRs with poor user interfaces for EHRs with smoother interfaces, according to the AMA.

In 2013, the AMA and RAND conducted a study in which doctors identified EHRs as the leading cause of professional dissatisfaction, emotional fatigue, depersonalization and lost enthusiasm.

In the study, physicians also described poor EHR usability that did not match clinical workflows, time-consuming data entry, interference with face-to-face patient care, and overwhelming numbers of electronic messages and alerts.

Those findings were backed up by a survey conducted by research firm Frost & Sullivan in conjunction with the College of Health Information Management Executives. In the survey, CIOs identified key "pain points" in EHR use, including time-consuming data entry tasks and significant difficulties in finding and reviewing data. In addition, executives cited the inability to create targeted queries or easily access unstructured data such as clinician notes as a major pitfall-all reasons for CIOs switching EHRs, the report finds.

Why is usability such a big issue?

"The problem is that we're still in the infancy of electronic health records compared to a lot of other technologies," says Kenagy. "Computers in hospitals and healthcare organizations are still fairly new. Meaningful use [the government's EHR incentive program] brought in a lot of money to have a lot of people adopt EHRs. The tools are still pretty new as is the physician knowing how to use it."

It's no surprise, then, that providers are adopting EHR systems, only to replace them with what they view as more mature technology over time.

The move to consolidate

In addition to wanting better EHR usability, Kenagy says switching vendors at Legacy Health was part of an overall strategy that called for the integration of inpatient, emergency department and outpatient EHRs. "That's why we chose Epic," he adds. "We chose a new product that would really work well clinically, providing an integrated health record across all the domains. The value of a single electronic health record is extremely powerful."

The Mayo Clinic in mid-January also consolidated EHRs, selecting Epic to be its single, integrated electronic health record and revenue cycle management system, replacing three other EHRs. "With our staff working together on a common system, we will be able to accelerate innovation, enhance services and provide a better experience for our patients," says Dawn Milliner, M.D., Mayo Clinic's chief medical information officer, in a statement.

The integrated EHR/RCM system will be built this year and next, with implementation planned to begin in 2017. The system will be a "foundation for Mayo Clinic operations over the next several decades," according to the announcement. Ultimately, more than 45,000 Mayo staff will be trained to use the new system.

Novant Health Medical Group, a physician-led organization of more than 1,700 primary and specialty care providers in the southeast, also switched to Epic from a plethora of other EHR vendors. "As we had grown over the years, we incorporated individual clinics that already had purchased their own EHRs with probably every EHR vendor there is represented," says Keith Griffin, M.D., Novant Health Medical Group's CMIO, who estimates the organization converted more than 50 EHRs.

"The big driver was the complication of having a hundred different billing office systems," says Griffin. "It was a real nightmare for us in terms of managing the complexity. So, that was part of the driver-to have a really efficient billing office, and you can only do that if you're on one common platform. The other big driver, of course, was having clinical data in one place, giving us a patient-centric record instead of a clinic-centric record-which is what we had before."

Functionality concerns

CaroMont Health, a regional, not-for-profit healthcare system in Gastonia, N.C., was a longtime Siemens customer. But, according to Mike Johnson, CIO of CaroMont, his organization "got to the point where we decided to switch out because we just didn't think the features/functions were there and we weren't confident that the vendor was going to be able to survive in the marketplace." Siemens' health IT unit, which is in the process of being bought by Cerner, declined to comment for this article.

Siemens EHR system remains one of the more popular among hospital customers. However, Johnson says the system provided insufficient physician documentation and no single place for a patient portal.

CaroMont also has acquired 45 practices and was looking to move to a single system. "We're convinced that an integrated approach is better," Johnson remarked.

Move cautiously

Allscript's Berner recommends that before a rip-and-replace, providers identify the specific problems they are trying to solve.

Michael Lovett, executive vice president and general manager of NextGen Healthcare, agrees that there has to be a compelling reason to take such drastic and costly action. While the reasons for deciding to implement a new EHR differ depending on provider needs, identifying an under-performing EHR and replacing it with a solution that delivers results is not an easy task.

For those thinking of switching EHRs, the design, implementation, use and maintenance of these systems raises important concerns for providers that must be addressed. Until they are, the full promised benefits of EHRs will remain elusive.

Griffin says providers considering switching EHR vendors have to be realistic about what is involved and that "there are a lot of costs and heavy lifting associated with this kind of effort." EHR software can be a big investment including high up-front costs, pricey upgrades and hidden maintenance fees. He recommends taking a team approach to the switchover in what is a rapidly changing EHR environment.

As providers contemplate a switch, they should evaluate an EHR vendor's track record, data migration approach, workflow design and total cost of ownership, among other areas. Large healthcare organizations in particular should strongly consider using a consultant to help manage the EHR selection, implementation and post-implementation phases.

"Make sure you have unwavering executive support and that you engage clinicians in making the decision," advises Kenagy. "You're going to spend a lot of money and a lot of time. It is expensive but if there's value for your organization, then do it well."

STICKING WITH AN EHR

In some cases, optimizing an existing EHR may be a better option than replacing it outright. Case in point: The 28-provider United Regional Physician Group in Wichita Falls, Texas, had an EHR that by all accounts was not working well, causing dissatisfaction among clinicians and staff members. United Regional considered replacing it, but in the end, with the help of ECG Management Consultants, took the optimization path.

The system's poor usability was a key issue, according to Michelle Holmes at ECG, and "when they lifted up the hood what they discovered was that a lot of the parts of the system that would enable them to improve their revenue cycle just were never implemented-they weren't turned on and users didn't know how to use them." United Regional's original EHR rollout was an example of "an initial implementation that was under-staffed, didn't go very well, and most of the users hadn't been fully trained," she says.

ECG helped United Regional restructure its support team and establish a governance structure. "We helped them clean up and reconfigure the things that hadn't been done well or done completely during their initial install," says Holmes. "We added some third-party functionality to help with the usability issues. Then, we focused on workflow and training."

At October's MGMA Conference in Las Vegas, United Regional's director Taraq Mazher told an audience that with the help of ECG new policies and procedures were created for enhancement requests, communications, change control, downtime and the service desk, with logging and tracking of all requests. Taraq was not available to comment for this article.

If a provider came to ECG today in a similar situation to United Regional and asked if it should replace its EHR, Holmes says she would tell the provider to "hold tight" because a lot can change for the better. -G.S.

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